LINC 2019 live case guide


Find all live cases and live case centers listed below.

 

 

Conference day 1

  • - , Room 1 - Main Arena 1

    Case 01 – Calcified SFA-occlusion right

    Center:
    Leipzig, Dept. of Angiology
    Case 01 – LEI 01: male, 75 years (M-K)
    Operators:
    • Andrej Schmidt,
    • Matthias Ulrich
    CLINICAL DATA
    Severe claudication right calf, walking capacity 100 meters,
    ABI right 0.54, Rutherford class 3
    PTA both EIA 10/2014 and left SFA 12/2014
    CAD, AMI 02/2014
    Mild renal impairment

    RISK FACTORS
    Arterial hypertension, hyperlipidemia, former smoker

    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
    - Command 18 and Armada 18 balloon (ABBOTT) or
    - 0.035“ Radiofocus soft angled guidewire, 260 cm (TERUMO)
    3. In case of failure to pass the CTO
    - GoBackTM Crossing Catheter (Upstream Peripheral)
    4. PTA
    - 4.0 – 6.0 mm Armada 35 balloon (ABBOTT)
    - Conquest high pressure balloon on indication (BARD)
    5. Stenting
    - 5.0 or 6.0/150 mm Supera Interwoven Selfexpanding Nitinol stent (ABBOTT)
    View image
  • - , Room 2 - Main Arena 2

    Case 09 – Woven nitinol stent for chronic total occlusion of common femoral vein

    Center:
    Zürich
    Case 09 – ZUE 01: male, 39 years (FJ-C)
    Operators:
    • Nils Kucher,
    • Dai-Do Do
    CLINICAL DATA
    Severe post-thrombotic syndrome right leg
    History of provoked deep venous thrombosis left leg 2009

    PRESENT STATE
    Villalta score: 12 points
    Hetercygote Faktor-V Leiden mutation

    DUPLEX
    Right leg: chronic thrombosis of common femoral and femoral vein
    Patent iliac veins

    PROCEDURAL STEPS
    1. Analgosedation propofol, fentanyl; ultrasound-guided access: of the size and location of metastases.
    2. Lesion examination with selective venography in two orthogonal views, deep femoral vein imaging using balloon occlusion venography of common femoral vein, provisional IVUS
    3. Passage of femoral vein occlusion using stiff angled glidewire 0.035“, Astato 0.018“ 30 g tip load, angled 0.035“ CXI support catheter
    4. Balloon angioplasty up to 12 mm high pressure of common femoral vein, provisional cutting ballon up to 8 mm
    5. Placement of Blueflow stent (14 x 100 mm or 14 x 150 mm) likely from the jugular approach
    6. Postdilatation high pressure of Blueflow up to 14 mm (ATLAS GOLD, BARD)
    7. Final venograms and assessment of peak flow velocity in common femoral vein by Duplex sonography
    View image
  • - , Room 1 - Main Arena 1

    Case 02 – Calcified CTO of the left distal SFA and left popliteal artery

    Center:
    Leipzig, Dept. of Angiology
    Case 02 – LEI 02: male, 73 years (W-H)
    Operators:
    • Sven Bräunlich,
    • Axel Fischer
    CLINICAL DATA
    PAOD Rutherford III left, painfree walking distance 100 m, ABI left: 0,5
    CAD, ICM (EF 32%), AMI 2014 and 12/2018, CABG 2014, PTCA 12/18
    Renal impairment

    RISK FACTORS
    Arterial hypertension, diabetes mellitus type 2 with angio- and neuropathy, hyperlipidemia

    PROCEDURAL STEPS
    1. Right 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
    - Command 18 and Armada 18 balloon (ABBOTT) or
    - 0.035“ Radiofocus soft angled guidewire, 260 cm (TERUMO) and
    4.0/120 mm Armada 35 balloon (ABBOTT)
    - 5.0/40 mm Armada 35 balloon (ABBOTT)
    3. Stenting
    - 5.0/150 mm Supera Interwoven Selfexpanding Nitinol stent (ABBOTT)
    View image
  • - , Room 2 - Main Arena 2

    Case 10 – Left ilio-femoral acute deep vein thrombosis

    Center:
    Galway
    Case 10 – GAL 02: female, 45 years (K-B)
    Operators:
    • Gerard O'Sullivan
    CLINICAL DATA
    2 week history of low back pain, radiation to left groin,
    1 week history of a painful swollen leg
    No specific risk factors

    PROCEDURAL STEPS
    1. Pre op: CTPA to assess for pulmonary embolus CTV for intra-abdominal veins US to confirm popliteal vein is patent
    2. Initially supine; ultrasound guided puncture right internal jugular vein; Capturex device (STRAUB MEDICAL) in position – get the goalkeeper in place!
    3. Now turn prone; ultrasound guided puncture of left popliteal vein; 10F sheath; 5000u IV Heparin
    4. 65 cm torqueable catheter and 180 cm glidewire; once past lesion exchange for 0.025“ wire
    5. Aspirex Thrombectomy catheter (STRAUB MEDICAL)
    6. 8F Hockey Stick (CORDIS) for aspiration post thrombectomy – pay attention to profunda and internal iliac veins
    7. IVUS-Volcano (PHILIPS) to assess diameter and confirm need for a stent
    8. 14 mm ATLAS balloon (BARD) to 20 atm
    9. SINUS Venous 14/150 stent (OPTIMED) – slow deployment; repeat balloon to same diameter and pressure
    10. IVUS (PHILIPS) to confirm full stent expansion; followed by venography to confirm rapid flow
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  • - , Room 3 - Technical Forum

    Case 20 – Asymptomatic very high grade LICA-Stenosis in a young vascular polytrauma

    Center:
    Berlin
    Case 20 – BLN 02: male, 52 years (R-V)
    Operators:
    • Ralf Langhoff,
    • Andrea Behne
    CLINICAL DATA
    High grade bilateral ICA stenosis (left>right)
    Diabetic foot syndrom left
    Bilateral total SFA occlusions (PTA with DEB and Ultrascore 08/2018)
    Bilateral high grade CIA&EIA steosis (PTA and Stenting 08/2018
    Coronary disease (2 vessel, symptomatic)
    High grade left renal stenosis
    Left Subclavian artery high grade stenosis

    RISK FACTORS
    Smoker, diabetes mellitus, art. hypertension

    CT
    Aortic Arch Type 1, left ostial subtotal carotid artery stenosis

    DUPLEX
    High grade stenosis, not much calcium, straight vessel, soft plaques, high grade stenosis

    PROCEDURAL STEPS
    1. Transfemoral access
    - Short 8F sheath (TERUMO)
    2. Sheath placement
    - 8F MP-shape guiding catheter sheath into the left CCA (VISTA BRITE IG, CORDIS)
    3. Distal Protection
    - Filter-wire EZ protection system (BOSTON SCIENTIFIC), alternatively Emboshield Nav 6 (ABBOTT Vascular)
    4. Predilatation
    - 3 x 40 mm Maverick balloon (BOSTON SCIENTIFIC)
    5. Secondary protection/ stenting/ postdilatation
    - Neuroguard IEP stent 9 mm (CONTEGO MEDICAL) filter, Nitinol stent and postdilation balloon in one system
    6. Removal of the stent delivery system and Filter Wire EZ system (BOSTON SCIENTIFIC)
    7. Control angiography extra – and intracranial DSA
    8. Access care
    - Angioseal 8F (TERUMO)
    View image
  • - , Room 2 - Main Arena 2

    Case 11 – TASC D calcified iliac occlusion right

    Center:
    Leipzig, Dept. of Angiology
    Case 11 – LEI 06: male, 59 years (L-G)
    Operators:
    • Andrej Schmidt,
    • Matthias Ulrich
    CLINICAL DATA
    Severe claudication right, walking-capacity 50-100 meters
    Rutherford class 3, ABI right 0.46
    COPD

    RISK FACTORS
    Arterial hypertension, hyperlipidemia, strong smoker (50PY)

    PROCEDURAL STEPS
    1. Right femoral access
    - 7F 25 cm Radiofocus Introducer (TERUMO)
    - 0.035“ SupraCore guidewire 300 cm (ABBOTT)
    Left brachial approach:
    - 6F 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
    - Ultraverse or Dorado balloon (BARD)
    - LifeStream covered stent 8/58 mm bilateral common iliac arteries in kissing-technique (BARD)
    - Covera Plus vascular covered stent for the external iliac artery (BARD)
    View image
  • - , Room 1 - Main Arena 1

    Case 03 – Occlusion of the right SFA

    Center:
    Leipzig, Dept. of Angiology
    Case 03 – LEI 03: male, 74 years (P-V)
    Operators:
    • Sven Bräunlich,
    • Manuela Matschuck
    CLINICAL DATA
    PAOD Rutherford 3, walking capacity 100 m, ABI right 0.55, left 0.6
    Failed recanalisation attempt of the right SFA 08/12 elsewhere
    Renal impairment grade 2

    RISK FACTORS
    Aterial hypertension, former nicotine abuse (20PY), hyperlipidemia

    PROCEDURAL STEPS
    1. Left groin and cross-over approach
    - Judkins Right 5F diagnostic catheter (CORDIS/CARDINAL HEALTH)
    - 0,035“ SupraCore guidewire 30 cm (ABBOTT)
    - 6F 40 cm Balkin Up&Over sheath (COOK)
    2. Guidewire passage of the occlusion
    - 0.035“ Halfstiff TERUMO 260 cm (TERUMO)
    - 0.035“ QuickCross support catheter, 135 cm (PHILIPS)
    3. PTA with scoring ballon
    - 4/40 mm AngioSculpt PTA scoring balloon (PHILIPS)
    4. PTA with DCBs
    - Stellarex 5.0/120 mm DCBs (PHILIPS)
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  • - , Room 3 - Technical Forum

    Case 21 – Symptomatic left carotid artery disease in a patient with coronary artery disease

    Center:
    Bergamo
    Case 21 – BG 02: male, 64 years (D-V)
    Operators:
    • Fausto Castriota,
    • Antonio Micari
    CLINICAL DATA
    Stable angina during the last 12 months, 1 hospital admission for TIA (transient dysartria) 1 month ago

    RISK FACTORS
    Hypertension, hypercholesterolemia

    DUPLEX
    Critical LICA stenosis with evidence of a ‚soft‘ plaque

    PROCEDURAL STEPS
    1. Femoral access
    2. Selective angiography
    3. Cerebral protection
    - MOMA 9F (MEDTRONIC) positioning
    4. Stenting
    - C-Guard (Inspire MD)
    5. Postdilatation
    - 5,0/20 mm balloon (BOSTON SCIENTIFIC )
    6. Femoral access haemostasis
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  • - , Room 2 - Main Arena 2

    Case 12 – Endovascular Y-reconstruction of chronic total occlusion of infrarenal inferior vena cava and iliofemoral veins

    Center:
    Zürich
    Case 12 – ZUE 02: male, 24 years, (F-A)
    Operators:
    • Nils Kucher,
    • Dai-Do Do
    CLINICAL DATA
    Massive descending bilateral iliofemoral DVT in September 2018 including the infrarenal IVC diagnosed late
    and treated conservatively, ongoing shortness of breath, ongoing severe spinal and biliateral leg claudication,
    limited physical performance since childhood

    PRESENT STATE
    Villata score: 6 points;
    Spiroergometry: limited oxygen uptake during exercise due to impaired venous return

    CT VENOGRAPHY
    Obtained 4 weeks after onset of symptoms:
    - chronic total occlusion of perirenal inferior vena cava with descending DVT into both iliac and common femoral veins
    - acygos collaterals

    DUPLEX
    Preserved leg inflow veins

    PROCEDURAL STEPS
    1. General anaesthesia, ultrasound-guided access bilateral femoral veins (below occlusion) and possibly right jugular vein (10F)
    2. Passage of occlusion of vena cava and iliac veins stiff angled glidewire 0.035“, Astato 0.018“ CTO wire with 30 g tip load
    3. Lesion examination by selective venograpy two planes, intra-occlusion venography and provisional IVUS
    4. High pressure balloon angioplasty up to 20 mm in vena cava, up to 14 mm iliac veins
    5. Stenting of IVC with 20 mm Venovo stent (BARD) with high pressure postdilation up to 20 mm (ATLAS GOLD, BARD)
    6. Y-reconstruction of iliac confluens using Venovo (BARD) 14 mm kissing stents
    7. Kissing balloon postdilation of iliac confluens with 14 mm ATLAS GOLD balloons (BARD)
    8. Stent extension to both common femoral veins using Venovo 14 mm stents (BARD) with postdilation up to 14 mm high pressure
    9. Final venograms and assessment of peak flow velocity in both common femoral veins by Duplex sonography
    View image
  • - , Room 2 - Main Arena 2

    Case 13 – May-Thurner-Syndrome left

    Center:
    Galway
    Case 13 – GAL 03: male, 55 years
    Operators:
    • Gerard O'Sullivan,
    • M. Mullin
    CLINICAL DATA
    55 year old male presents with left lower limb swelling, pain and impending ulceration of the left lateral gaiter region December 2017.
    Background History:
    Antiphospholipid syndrome complicated by reccurent left sided DVT and PE
    Aortic valve replacement complicated by subdural haematoma, requiring evacuation 2013
    Recurrent subdural and subarachnoid haemorrhages due to lifelong anticoagulation

    IMPORTANT ITEMS
    Antiphospholipid syndrome
    DVT and PE. IVC filter in situ
    Recurrent subdural and subarachnoid haemorrhages
    CT venogram: IVC filter
    Left sided May-Thurner syndrome
    Bilateral lower limb varicose veins, including enlarged left greater saphenous vein.
    Severe ulceration along LATERAL border left foot – normal ABPIs

    PROCEDURAL STEPS
    1. CT venogram. Supine. General anaesthetic. Urethral catheter
    2. Right internal jugular vein puncture
    - 5F microaccess kit (COOK); 10F 23 cm sheath
    3. Guidewire placement
    - 260 cm Glidewire and 100 cm kumpe catheter to left common femoral vein.
    - 5000uIV Heparin.
    4. Biplanar venography
    - (AP and LAO for left) and IVUS Volcano (PHILIPS) evaluation;
    - left iliac system under pressure; but right may be abnormal also IVUS very helpful in this regard
    5. Balloon angioplasty from the common femoral veins to the renal IVC
    - 14 - 16 mm angioplasty @ 18–20 atm (ATLAS, BARD) of the common femoral and external iliac veins
    - 16 - 18 mm ATLAS (BARD) @ 18–20 atm of the common iliac vein
    6. Stenting
    - Abre (MEDTRONIC), Zilver Vena (COOK) or Venovo (BARD) 16/14mm diameter – uncertain of length as yet – stent from normal to normal
    7. Post stent balloon dilatation to nominal diameter stents
    8. Repeat venography and IVUS
    9. Post-op care
    - Pneumatic boots until discharge and class II thigh high stockings 3/12
    - Anticoagulation for life as per haematology department
    - Follow-up colour doppler US day one post-op
    - Follow-up CT venogram 6/52
    - CTV at 6/52
    View image
  • - , Room 2 - Main Arena 2

    Case 14 – Endovascular Y-reconstruction of chronic total occlusion of entire suprarenal and infrarenal inferior vena cava and iliac veins

    Center:
    Zürich
    Case 14 – ZUE 03: male, 46 years (W-C)
    Operators:
    • Nils Kucher,
    • Dai-Do Do
    CLINICAL DATA
    Limited physical performance
    History of acute venous thrombosis right common iliac vein (2013)
    Several catheterizations as newborn

    IMPORTANT ITEMS
    MR-venography: atresia of entire inferior vena cava starting from the liver veins, bilateral common iliac vein occlusion, prominent collateral veins (vena azygos and lumbar veins)
    Spiroergometry: limited oxygen uptake during exercise due to impaired venous return (60% of norm)
    Villalta score: 9 points

    DUPLEX
    patent common femoral veins

    PROCEDURAL STEPS
    1. General anaesthesia, Ultrasound-guided access:
    right and left common femoral veins and possibly right jugular veins (10F)
    2. Passage of occlusion of vena cava and iliac veins using stiff angled glidewire 0.035“, Astato 0.018“ CTO wire with 30 g tip load, angled CXI 0.035“ support catheter
    3. Lesion examination by selective venograpy two planes, intra-occlusion venography and provisional IVUS
    4. High pressure Balloon angioplasty up to 20 mm in vena cava, up to 14 mm iliac veins
    5. Stenting of IVC with two overlapping 20 mm Venovo (BARD) stents and high pressure postdilation up to 20 mm (ATLAS GOLD, BARD)
    6. Y-reconstruction of iliac confluens using Venovo 14 mm kissing stents (BARD)
    7. Kissing Balloon postdilation of iliac confluens with 14 mm ATLAS GOLD balloons (BARD)
    8. Possibly stent extensions to both external iliac veins using Venovo 14 mm stents (BARD) with postdilation up to 14 mm high pressure
    9. Final venograms and assessment of peak flow velocity in both common femoral veins by Duplex sonography
    View image
  • - , Room 2 - Main Arena 2

    Case 13 – May-Thurner-Syndrome left

    Center:
    Galway
    Case 13 – GAL 03: male, 55 years
    CLINICAL DATA
    Limited physical performance
    History of acute venous thrombosis right common iliac vein (2013)
    Several catheterizations as newborn

    IMPORTANT ITEMS
    MR-venography: atresia of entire inferior vena cava starting from the liver veins, bilateral common iliac vein occlusion, prominent collateral veins (vena azygos and lumbar veins)
    Spiroergometry: limited oxygen uptake during exercise due to impaired venous return (60% of norm)
    Villalta score: 9 points

    DUPLEX
    patent common femoral veins

    PROCEDURAL STEPS
    1. General anaesthesia, Ultrasound-guided access:
    right and left common femoral veins and possibly right jugular veins (10F)
    2. Passage of occlusion of vena cava and iliac veins using stiff angled glidewire 0.035“, Astato 0.018“
    CTO wire with 30 g tip load, angled CXI 0.035“ support catheter
    3. Lesion examination by selective venograpy two planes, intra-occlusion venography and provisional IVUS
    4. High pressure Balloon angioplasty up to 20 mm in vena cava, up to 14 mm iliac veins
    5. Stenting of IVC with two overlapping 20 mm Venovo (BARD) stents and high pressure postdilation up to 20 mm (ATLAS GOLD, BARD)
    6. Y-reconstruction of iliac confluens using Venovo 14 mm kissing stents (BARD)
    7. Kissing Balloon postdilation of iliac confluens with 14 mm ATLAS GOLD balloons (BARD)
    8. Possibly stent extensions to both external iliac veins using Venovo 14 mm stents (BARD) with postdilation up to 14 mm high pressure
    9. Final venograms and assessment of peak flow velocity in both common femoral veins by Duplex sonography
    View image
  • - , Room 3 - Technical Forum

    Case 23 – Long calcified SFA-occlusion left

    Center:
    Leipzig, Dept. of Angiology
    Case 23 – LEI 07: male, 61 years (R-F)
    Operators:
    • Sven Bräunlich,
    • Andrej Schmidt
    CLINICAL DATA
    Severe claudication left calf, walking capacity 50 meters, ABI left 0.62
    Femoro-popliteal bypass right 2012, thrombendatherectomy left groin 01/2019
    CEA left 11/2012 and right 12/16, CAD, AMI 1997

    RISK FACTORS
    Art. hypertension, diabetes mellitus type 2, nicotine abuse (80PY), hyperlipidemia

    PROCEDURAL STEPS
    1. Right groin and cross-over access
    - 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. Antegrade guidewire-passage
    In case of failure from antegrade:
    Retrograde GW-passage via proximal ATA
    - 21 Gauge 9cm needle (B.BRAUN)
    - 0.018” V-18 Control GW, 300cm (BOSTON SCIENTIFIC)
    - 0.018” CXC Support-Catheter, 90cm (COOK)
    3. In case of failure to pass the guidewire
    - retrograde approach via distal SFA or GoBackTM Crossing Catheter (Upstream Peripheral) from antegrade
    4. Tumescent anesthesia of the SFA
    - Bullfrog-Device (MERCATOR)
    5. PTA/ vessel preparation
    - Sterling 5/100 mm balloon (BOSTON SCIENTIFIC)
    - Conquest High pressure balloon on indication (BARD)
    6. Differential stenting
    - Eluvia DES in case of minor recoil (BOSTON SCIENTIFIC)
    - Supera Interwoven Nitinol-Stent in case of severe recoil (ABBOTT)
    View image
  • - , Room 1 - Main Arena 1

    Case 04 – Chronic total occlusion right SFA

    Center:
    Leipzig, Dept. of Angiology
    Case 04 – LEI 04: female, 76 years (M-R)
    Operators:
    • Matthias Ulrich,
    • Manuela Matschuck
    CLINICAL DATA
    Severe claudication both calves, walking capacity 20 meters
    Obesitiy, renal impairment G3, ICM, mycardial infarction 2009
    ABI right: 0.53 and left: 0.64

    RISK FACTORS
    Arterial hypertension, former smoker

    ANGIOGRAPHY
    11/2018: long SFA-occlusions both sides, moderate 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 (ABBOOTT)
    - 6F Balkin Up&Over sheath, 40 cm (COOK)
    2. Passage of the occlusion of the 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 with DCBs
    - 5.0 mm Chocolate balloon (MEDTRONIC)
    - 6.0/120 mm In.Pact Pacific DCB (MEDTRONIC)
    4. Stenting on indication
    - Complete Selfexpanding Nitinol stent (MEDTRONIC)
    View image
  • - , Room 2 - Main Arena 2

    Case 15 – Failing dialysis graft

    Center:
    Galway
    Case 15 – GAL 04: male, 66 years (H-G)
    Operators:
    • Gerard O'Sullivan,
    • G. Rahmani
    CLINICAL DATA
    End stage renal disease. On maintenance haemodialysis through a right arm arterio-venous fistula-brachiocephalic.
    High venous pressures with excessive bleeding post HD

    RISK FACTORS
    Diabetes mellitus, haemodialysis

    PROCEDURAL STEPS
    1. Supine, local anaesthetic, right arm AV access towards heart
    - 9F sheath
    - 3000u IV Heparin
    2. Initial venography to confirm lesion and measure appropriate diameter and length
    3. Cross lesion under roadmap control; predilatation with 8 mm balloon
    4. Lutonix (BARD) 8/40 drug eluting balloon
    5. Covera (BARD) 8/60, 9/60, 10/60 stent graft
    6. Completion venography
    7. Purse string suture
    8. Anti-platelet medications NSA 300mg stat and 75 mg/d x life
    View image
  • - , Room 1 - Main Arena 1

    Case 05 – Severe diffuse left SFA disease with distal occlusion

    Center:
    New York
    Case 05 – NY 01: female, 75 years, (S-C)
    Operators:
    • Prakash Krishnan,
    • Vishal Kapur
    CLINICAL DATA
    Left leg claudication x 6 months (< 3 blocks)
    Failed exercise therapy and a trial of Cilostazol
    ABI (R/L) 0.92/0.71

    RISK FACTORS
    Type 2 DM, HTN, dyslipidemia

    DUPLEX
    Suggestive of distal left SFA occlusion

    PROCEDURAL STEPS
    1. Right CFA access
    - Micropuncture sheath (COOK)
    2. Access sheath
    - 6F 45 cm crossover Destination sheath (TERUMO)
    3. Antegrade lesion crossing
    - 0.035“ stiff angled glidewire (TERUMO)
    4. Embolic protection
    - Emboshield Nav 6 (4-7) filter deployment (ABBOTT)
    5. Ultrasound
    - Vision PV 0.14 intravascular ultrasound (PHILIPS)
    6. Atherectomy
    - Directional atherectomy, Hawk M (MEDTRONIC)
    7. Angioplasty
    - Drug coated balloon angioplasty IN.PACT Admiral balloon (MEDTRONIC)
    8. Stenting
    - Stent scaffold for severe flow limiting dissection
    View image
  • - , Room 3 - Technical Forum

    Case 25 – Right common and external iliac artery occlusion

    Center:
    New York
    Case 25 – NY 03: male, 57 years (P-P)
    Operators:
    • Prakash Krishnan,
    • Vishal Kapur
    CLINICAL DATA
    Progressively worsening claudication of right lower extremity x 1 year.
    Failed exercise therapy and unable to tolerate Cilostazol.
    Unsuccessful attempt of right Iliac angioplasty at outside facility.
    ABI 0.56/0.92.

    RISK FACTORS
    Type 2 DM, HTN, dyslipidemia, CKD

    PROCEDURAL STEPS
    1. Right radial artery access
    - 6-7 Slender sheath (TERUMO)
    2. Right CFA access
    - Micropuncture sheath (COOK) under Road Map guidance
    3. Antegrade lesion crossing
    - 0.014“ wire platform
    Wire escalation to 0.018“ to 0.035“ in sequential fashion
    If fails will attempt retrograde
    4. Wire externalization
    5. Predilatation
    - 6.0 x 60 mm Dorado balloon (BARD)
    6. Stenting
    - Viabhan VBX stent (GORE)
    View image
  • - , Room 5 - Global Expert Exchange

    Case 29 – Diabetic foot syndrome with CTO of tibioperoneal trunc and distal occlusion of the ATP

    Center:
    Berlin
    Case 29 – BLN 04: male, 62 years, (J-B)
    Operators:
    • Ralf Langhoff,
    • Mehmet Boral
    CLINICAL DATA
    Gangrene Dig. ped. II right, persistend occlusion of right tibioperoneal trunc
    Diabetes mellitus
    Minor amputation of right foot Dig ped I ex-articulation of end-phalanx
    PTA and Supera stenting right SFA & popliteal artery 01/2019
    Impaired renal function
    TEA and Patch bilateral common femoral artery (2015)

    RISK FACTORS
    Hyperlipidemia (Lipidapharesis since 2016), art. hypertension
    CHD (post-MI), recanalisation of inflow was done by cross-over approach,
    wound is only slowly improving

    PROCEDURAL STEPS
    1. Antegrade access
    - Destination 5F sheath (45 cm) right CFA (TERUMO)
    2. Recanalisation
    - supported by CXI Supportcatheter 0.018“ (COOK) and Advantage Glidewire 0.018“ (TERUMO)
    3. PTA
    - 2 x 40 mm ballon Passeo 18 (BIOTRONIK)
    4. Recanalisation of the tibioperoneal trunc & distal ATP to the pedal arch and PTA
    5. Stenting of the tibioperoneal trunc
    - 3.0 x 31 mm Cre8 BTK dedicated DES (ALVIMEDICA)
    6. BACK-UP: transpedal-loop recanalisation of the ATP via the ATA
    - 0.014“ Corsair Microcatheter (ASAHI) and 0.014“ Advantage Wire (TERUMO)
    View image
  • - , Room 2 - Main Arena 2

    Case 16 – Rapidly progressing right carotid artery disease in a 55-yrs old patient

    Center:
    Bergamo
    Case 16 – BG 01: female, 55 years (C-C)
    Operators:
    • Fausto Castriota,
    • Antonio Micari
    CLINICAL DATA
    CVRFs: hypertension, hypercholesterolemia
    Unstable angina treated with PCI to LAD (DES) in December 2018 (need for 12-month double antiplatelet therapy)

    DUPLEX
    Critical RICA stenosis (NASCET 80%) with evidence of a ‚soft‘ fast-growing plaque (40% at Duplex scan performed in January 2018)

    PROCEDURAL STEPS
    1. Femoral access
    2. Selective angiography
    3. Cerebral protection
    - MOMA 9F (MEDTRONIC) positioning
    4. Stenting
    - Roadsaver (TERUMO) stent
    5. Postdilatation
    - 5,0/20 mm balloon (BOSTON SCIENTIFIC)
    6. Femoral access haemostasis
    View image
  • - , Room 1 - Main Arena 1

    Case 06 - Post cancer IVC and iliac vein occlusion with impending ulceration

    Center:
    Galway
    Case 06 – GAL 01: male, 26 years
    Operators:
    • Gerard O'Sullivan,
    • M. Mullin
    PATIENT DATA
    26 year old male, initially presented with a scrotal mass (July 2017), and was found to have metastatic testicular cancer. Subsequent CT demonstrated large retroperitoneal lymph nodes and IVC; 3 months
    into treatment he developed right iliofemoral and left common iliac venous thrombosis. He was treated with therapeutic Innohep (Figure 1). Unfortunately, whilst on treatment, he suffered a further left lower limb DVT in October 2017. Gradually worsening swelling both legs, worse on the right. The patient was referred to the IR clinic in December 2018 with bilateral lower limb swelling and signs of chronic venous hypertension (Figure 2).

    CLINICAL DATA
    In complete remission from original cancer. Worsening right leg swelling – impending ulceration;
    frequent sick leave; barely able to hold down a job. Works as a foreman in a yard.

    PRESENT STATE
    Bilateral lower limb post thrombotic syndrome and chronic venous hypertension December 2018.
    MRV demonstrates an occluded and fibrotic infrarenal IVC and common iliac veins with reconstitution at the level of the common femoral vein (Figures 3–5). The patient had also developed numerous abdominal
    wall collateral veins.

    PROCEDURAL STEPS
    1. Pre-op: Bloods: FBC, U&E, Coag; MR venogram, general anaesthetic, urethral catheter
    2. Right internal jugular access 10F sheath; bilateral common femoral vein puncture using 5F microaccess kit (COOK) – attempt to cross from neck initially; 7500uIV Heparin
    3. Crossing cather (CXI/CROSSER/RUBICON) to get from above to below or visa versa.
    MUST USE FREQUENT LATERAL PROJECTIONS TO CONFIRM WIRES LIE ANTERIOR TO VERTEBRAL BODIES.
    4. Biplanar venography (AP and LAO for left, AP and RAO for right) and IVUS (VOLCANO, PHILIPS) evaluation
    5. High pressure balloon predilatation (ATLAS, BARD) 14 mm kissing throughout IVC and Iliac veins to groins
    6. Stents Veniti Vici (BOSTON SCIENTIFIC) 14_120 kissing IVC and CIVs_ Wallstents 14_90 (BOSTON SCIENTIFIC) into groins_NORMAL to NORMAL
    7. Post dilatation to same diameter and pressure
    8. IVUS and venography
    9. In case of rupture back up 12F sheaths and GORE Viabahn 13 mm_100
    10. Standard post op care_ boots_ stockings_ maintain full anticoagulation; Colour Doppler Day 1 and CTV at 6 weeks
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  • - , Room 2 - Main Arena 2

    Case 17 – High-grade, progressive RICA post radiation and open surgery for parotid tumor

    Center:
    Berlin
    Case 17 – BLN 01: male, 62 years, (J-B)
    Operators:
    • Ralf Langhoff,
    • Andrea Behne
    CLINICAL DATA
    Radiation and open surgery due to parotid cancer (years ago)
    Renal insufficiency (last Creatinin level 2.3 mg/dl)

    DUPLEX
    High grade RICA, PSV 364 cm/sec, EDV >100 cm/sec, MDV 100 cm/sec

    RISK FACTORS
    Ex-nicotine, art. hypertension

    PRESENT STATE
    CTA and MRA not available due to impaired renal function

    PROCEDURAL STEPS
    1. Transfemoral access
    - Short 8F sheath (TERUMO)
    2. Placement of the guiding catheter
    - 8F MP-shape guiding catheter sheath into the right CCA (VISTA BRITE IG, CORDIS)
    3. Distal Protection
    - Filter-wire EZ protection system (BOSTON SCIENTIFIC), alternatively Emboshield Nav 6 (ABBOTT Vascular)
    4. Predilatation
    - 3 x 20 mm Maverick balloon (BOSTON SCIENTIFIC)
    5. Stenting
    - Roadsaver 8 x 25 mm Micromesh-stent (TERUMO)
    6. Postdilatation
    - 5 x 20 mm Maverick balloon (BOSTON SCIENTIFIC)
    7. Removal of the stent delivery system and Filter Wire EZ system (BOSTON SCIENTIFIC)
    8. Control angiography extra – and intracranial DSA
    9. Access care
    - Angioseal 8F (TERUMO)
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  • - , Room 2 - Main Arena 2

    Case 19 – Chronic LLE swelling and venous claudication

    Center:
    Galway
    Case 19 – GAL 05: female, 34 years (L-E)
    Operators:
    • Gerard O'Sullivan
    CLINICAL DATA
    Moderately swollen left leg; marked varicose veins; significant venous claudication

    IMPORTANT ITEMS
    Developed LLE DVT 2012 while on OCP. Repeat DVT LLE 2016.
    No other risks. Non smoker. No longer on OCP. On life long anticoagulation.
    CTV shows left ilio-femoral venous occlusion

    PROCEDURAL STEPS
    1. Supine. GA. Urethral catheter.
    - RIJV 10F sheath 30cm long. Left femoral venous puncture mid thigh 4F catheter.
    - 5000u IV Heparin
    2. Crossing the lesion
    - 8F 55 cm Hockey stick to provide support. Crossing catheter (CXI); choice of wires - angled glide; stiff angled
    glide (both Merit Medical); Roadrunner (COOK)
    3. Confirm correct plane with oblique views, IVUS and venography.
    4. Predilatation
    - BARD ATLAS 16 mm @ >20 atm L CIV; 14 mm@ >20 atm LEIV L CFV
    5. Stenting
    - BARD Venovo or COOK Zilver Vena or MEDTRONIC ABRE of appropriate length
    6. Post dilatation to nominal dimater stents @ >20 atm
    7. Completion venography and IVUS
    8. Standard post op care
    - Pneumatic boots, stockings - Class 2 thigh high; maintain full AC; check CDUS day 1/30/180
    View image
  • - , Room 3 - Technical Forum

    Case 27 – Restenosis of the left common carotid artery after TEA

    Center:
    Leipzig, Dept. of Angiology
    Case 27 – LEI 09: female, 56 years (L-K)
    Operators:
    • Andrej Schmidt,
    • Sven Bräunlich
    CLINICAL DATA
    Asymptomatic highgrade stenosis of the the common carotid artery left, dizziness
    M. Hodgkin 1984 with cervical radiation
    CEA right 09/16 and CEA of left common carotid artery 05/17

    RISK FACTORS
    Art. hypertension, hyperlipidemia, former smoker

    DUPLEX
    4.8 m/sec. Left distal common carotid artery

    PROCEDURAL STEPS
    1. Right groin access
    - 5F Judkins Right diagnostic catheter (CORDIS/CARDINAL HEALTH)
    - 0.015“ SupraCore guidewire (ABBOTT)
    - 7F 90cm Check Flo Performer sheath (COOK)
    2. Cerebral protection
    - Filter-wire EZ (BOSTON SCIENTIFIC)
    3. Predilatation and Stenting
    - 3.5/20 mm MiniTrek Monorail balloon (ABBOTT)
    - 8/30 mm CGuard stent (InspireMD)
    View image
  • - , Room 1 - Main Arena 1

    Case 07 – Chronic CTO left SFA, CLI

    Center:
    Leipzig, Dept. of Angiology
    Case 07 – LEI 05: male, 64 years (P-W)
    Operators:
    • Sven Bräunlich,
    • Matthias Ulrich
    CLINICAL DATA
    Critical limb ischemia left, ulceration dig 4, Rutherford class 5
    Severe claudication left calf, walking capacity 50–100 meters,
    PTA/stenting left EIA 11/2018
    ABI left: 0.45

    RISK FACTORS
    Diabetes mellitus type 2, arterial hypertension, former smoker

    PROCEDURAL STEPS
    1. Right femoral access and cross-over approach
    - 6F 45 cm cross-over sheath Fortress (BIOTRONIK)
    2. Passage of the occlusion left SFA
    - 0.035“ Radiofocus angled stiff guidewire, 260 cm (TERUMO)
    - 0.035“ CXC support catheter, 135 cm (COOK)

    In case of failure guidewire passage from antegrade:
    3. Retrograde approach via distal SFA
    - 9 cm 20 Gauge spinal needle (BD)
    - 0.018“ V-18 Control guidewire, 300 cm (BOSTON SCIENTIFIC)
    - 4F 10 cm Radiofocus introducer (TERUMO)
    - Passeo 18 4.0/40 mm balloon, 90 cm (BIOTRONIK)
    4. PTA
    - Passeo 18 Ballon 5 x 150 mm (BIOTRONIK)
    - 5 mm Passeo 18 Lux DCB (BIOTRONIK)
    5. Stenting on indication, spot-stenting
    - Pulsar 18-T3 stent (BIOTRONIK)
    View image
  • - , Room 1 - Main Arena 1

    Case 08 – Calcified left superficial femoral artery

    Center:
    New York
    Case 08 – NYo2: male, 61 years (D-V)
    Operators:
    • Prakash Krishnan,
    • G. Dangas,
    • Vishal Kapur
    CLINICAL DATA
    Progressively worsening claudication of left lower extremity x 6 months
    Failed exercise therapy and Cilostazol 100 mg twice a day
    ABI 0.88/0.64

    RISK FACTORS
    Type 2 DM, HTN, dyslipidemia
    Remote TIA

    PROCEDURAL STEPS
    1. Right CFA access
    - Micropuncture sheath (COOK)
    2. Access sheath
    - 7F 45 cm Ansel cross-over sheath (COOK)
    3. Lesion crossing
    - 0.35“ stiff angled glidewire (TERUMO) supported by 0.35“ Navicross catheter (TERUMO)
    4. Embolic protection
    - Emboshield Nav 6 (4-7) filter deployment (ABBOTT)
    5. Ultrasound
    - Vision PV 0.14 intravascular ultrasound (PHILIPS)
    6. Lithoplasty
    - SHOCKWAVE Intravascular Lithotripsy (SHOCKWAVE Inc.)
    7. Stenting
    - Supera 6.0 x 150 mm stent (ABBOTT)
    View image