Guide to Live Case Transmissions

Transcription

L eipzig
I nte r venti o nal
C o u r se
2 0 1 6
January 26 – 29, 2016
Trade Fair Leipzig, Hall 4
Messe-Allee 1, 04356 Leipzig,
Germany
Guide to Live Case
Transmissions
www.leipzig-interventional-course.com
Get the LINC 2016 app for iPhone, iPad, and iPod
Programmesort the LINC programme by day, room, or faculty
member and view selected lectures the following day.
Exhibitors
view the list of all LINC exhibitors
and find their location on our
interactive floorplan.
Live Cases
sort the LINC live cases by day,
center, or operator and review
your favorite live cases the following day.
General Information
get all important informations
about and around LINC to
organise your personal LINC visit.
Faculty
find the schedule of your
favourite faculty members and
view LINC-produced interviews.
Get the LINC app now!
With a QR reader or
visit the app store.
This app was made possible by the friendly
and generous support of
Guide to Live Case Transmissions
During the Leipzig Interventional Course 2016
more than 90 interventional and surgical
live cases are scheduled to be performed and
transmitted to the auditorium. The aim of this
booklet is to give you an overview about the
live case schedule and to provide a practical
guide through the procedures.
We hope for your understanding that with
respect to the clinical needs of the patients
changes of the schedule may occur.
Furthermore, the anticipated procedural steps
are just an outline of the procedure.
Depending on the discretion of the operator
the procedural strategy or the choice of
material may vary.
1
2
Tuesday
L e i p z i g
I n t e r v e n t i o n a l
C o u r s e
2 0 1 6
Procedural
steps
Tuesday,
January 26, 2016
3
Tuesday, 08:24 – 08:44 and 09:08 – 09:30 Live from Leipzig Main Arena 1 · Room 1
Case 01 – LEI 01: male, 72 years (H-L)
Highly calcified distal SFA / A. popliteal occlusion left
Operators: A. Schmidt, M. Ulrich
Clinical data: Rest pain left foot, Rutherford class 4
Severe claudication left, walking capacity 100 meters
Angiography during PTA right iliac arteries after coronary angiography 12/2015
ABI:
Left 0.42
Risk factors:
CAD with PTCA 12/2015
Carotid TEA bilateral (1999 and 2000)
Permanent atrial fibrillation
Chronic renal insufficiency GFR 62 ml/min
Former smoker, art. hypertension, hyperlipidaemia
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 of the occlusion left SFA/Apop
■ 4.0/80 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 antegrade failure:
3. Retrograde approach via the proximal anterior tibial artery
■ 21 Gauge 7 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 Nitinolstent (ABBOTT)
4
Tuesday, 10:15 – 10:35 Live from Leipzig Main Arena 1 · Room 1
Case 02 – LEI 02: female, 75 years (W, U-I)
SFA-occlusion left, mildly calcified
Operators: A. Schmidt, Y. Bausback
ABI:
Left 0.62
Risk factors:
COPD
Gastric cancer, gastric resection/radiation 2003
Diabetes melllitus type 2
Procedural
steps
Tuesday
Clinical data: PAOD with severe claudication left calf, walking capacity 20 meters
CAD, PTCA 09/2015
■ 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 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 with a drug-coated balloon
■ Chocolate Touch 6.0/120mm (QTVascular)
4. Stenting on indication
■ VascuFlex Multi-LOC selfexpanding stent (B.BRAUN)
5
Case 03 – LEI 03: male, 62 years, (A-B)
Moderatly calcified SFA-occlusion left
Clinical data: Critical limb ischemia with forefoot ulcerations left,
Severe claudication left calf, walking capacity 200 meters
Rutherford class 5
Thromboendarterectomy left groin 11/2015
Persistent complaints, slow healing
ABI:
Left 0.51
Risk factors:
Current smoker
Art. hypertension
Latent hyperthyroidism
Procedural
steps
1.Right groin retrograde cross-over approach
■ 6F-55 cm Check-Flo Performer Sheath Raabe-modification (COOK)
■ 0.035" Radiofocus stiff angled guidewire, 260 cm (TERUMO)
2. Passage of the occlusion
■ 0.035" Radiofocus stiff angled guidewire, 260 cm (TERUMO)
■ Advance 35 mm balloon 4.0/120 mm (COOK)
3. Stenting and postdilatation
■ 6.0/120 mm Zilver-PTX Drug-eluting Stents (COOK)
■ Advance 35 5.0 or 6.0 mm /100 mm Balloon (COOK)
6
Tuesday, 11:53 – 12:15 Live from Dendermonde
Main Arena 1 · Room 1
Case 04 – DEN 01: male, 83 years (F-P)
TASC D SFA CTO left
Operators: K. Deloose, L. Maene
Angiography:
Procedural
steps
Tuesday
Clinical data: 2007 CAS Right
Since 3 months bilateral claudication left > right after <100 m (Rutherford 3)
Good CFA pulses
No popliteal / distal pulses
Risk factors:
Diabetes mellitus type 2, arterial hypertension
Hypercholesterolemia
MR Angio lower limbs
1. Right CFA access - crossover
■ 0.035", 260 cm Glide wire (Terumo)
■ RIM catheter (Cook Medical)
■ Destination 6F, 45 cm (Terumo)
2. Recanalization
■ 0.018", 260 cm Advantage (Terumo)
■ CXI catheter 0.018", 150 cm (Cook Medical)
3. Predilatation
■ Advance 18 LP, 5 mm (Cook Medical)
4. Stenting
■ ZILVER PTX (6 mm – 120 mm) (Cook Medical)
5. Post-dilatation
■ Advance 35 LP 6 mm (Cook Medical)
6. Assistance GE Healthcare
■ Vessel assist – "Center Line Tracking"
7. Plan B
■ Distal puncture + retrograde/bidirectional recanalization
7
Tuesday, 13:46 – 14:11 Live from Cotignola Main Arena 1 · Room 1
Case 05 – COT 01: female, 56 years (L-P)
Left SFA long occlusion
Operators: A. Micari, F. Castriota
Clinical data: Severe bilateral claudication
Previous right SFA and popliteal artery PTA with DEB (December 2015)
Risk factors:
Smoking, hypertension
Previous CABG (LIMA to LAD) in 2000
Severe left leg claudication
Angio:
Left SFA long occlusion
Procedural
steps
1. Contralateral (right) femoral access and placement of a cross-over sheath
■ 6F 45 cm Destination sheath (TERUMO)
2. Crossing the occlusion
■ 0.035'' Glidewire (Terumo)
3. Lesion predilatation
■ 4.0/120 mm Pacific balloon (Medtronic)
4. Dilatation
■ 5.0/120 mm Admiral Inpact balloon (Medtronic)
5. Spot stenting if needed
Angiography
(December 2015)
Right SFA and
popliteal artery PTA
(December 2015)
8
Tuesday, 14:35 – 15:00 Live from Leipzig
Case 06 – LEI 04: female, 66 years (I-B)
Occlusion right popliteal artery
ABI:
Right 0.55
PTA:
Right A.poplitea 3/2013
Duplex:
Moderate stenosis right iliac artery and reocclusion right popliteal artery
Risk factors:
Art. hypertension, diabetes mellitus type II, former smoker
Procedural
steps
Tuesday
Clinical data: Severe claudication right calf and restpain during night, Rutherford class 3-4
1.Left groin retrograde and cross-over approach
■ 7F-55 cm Check-Flow-Performer Sheath (COOK)
2. Passage of the popliteal occlusion right
■ 0.018" Victory 18 30 gr 300 cm guidewire (BOSTIN SCIENTIFIC)
3. Filter-protection placement
■ 4F-90 cm Check-Flo Performer sheath (COOK)
■ Wirion-Protection system (ALLIUM MEDICAL)
4. Atherectomy
■ HawkOne directional atherectomy system, 6 cm tip (MEDTRONIC)
5. PTA with Drug-coated balloons
■ In.Pact Pacific 6.0/120 mm (MEDTRONIC)
■ Complete SE-Stent
(MEDTRONIC)
9
Case 07 – LEI 05: male, 81 years (G-P)
BTK-occlusion right with critical limb ischemia
Clinical data: Restpain right forefoot and minor gangrene Dig I, Rutherford 5
Recurrent infrainguinal disease right with
PTA right SFA and BTK-arteries 4/2014 and 2/2015
Ischaemic cardiomyopathy, NYHA II-III
CAD with PTCA left main 2/2015
TAVI 2/2015
Permanent atrial fibrillation
PTA right vertebral artery 12/2015
ABI:
Right: 0.37
Angiography:
During vertebral artery PTA 12/2015: occlusion of all 3 BTK-arteries right
Risk factors:
Arterial hypertension, former smoker, hyperlipidaemia
Procedural
steps
1.Right antegrade approach
■ 6F 55 cm Flexor Check-Flo Introducer, Raabe Modification (COOK)
2. Passage of the anterior tibial artery occlusion
■ CXC 0.018” 90 cm Support-Catheter (COOK)
■ 0.018” V-18 Control Guidewire, 300 cm (BOSTON SCIENTIFIC)
Exchange to:
■ 0.014" Floppy ES 300 cm guidewire (ABBOTT)
3. PTA and arterial wall-injection
of dexamethason
■ Armada 14 3.0/120 mm balloon
(ABBOTT)
■ BullFrog Micro-Infusion-Device
(MERCATOR MEDSYSTEMS)
10
Tuesday, 16:44 – 17:10 Live from New York Main Arena 1 · Room 1
Case 08 – NYC 01: female, 83 years, (P-M)
Severely calcified severe stenosis of LSFA
Operators: P. Krishnan, K. Gujja, V. Kapur
Tuesday
Clinical data: PAD, Rutherford Class II, category III, claudication of L calf at 1 to 2 blocks,
ABI R LE - 0.5 and L LE - 0.6
Jet stream athrectomy , PTA and stenting of RSFA in 09/2015
Risk factors:Hypertension, diabetes mellitus type II,
dyslipidemia, moderate aortic regurgitation
Procedural
steps
1.Right common femoral access and cross over approach
■ 7 F Pinnacle destination sheath 45 cm up and over sheath (TERUMO)
2. Guidewire passage
■ 0.014" Spartacore wire, 300 cm (ABBOTT VASCULAR)
■ 0.038" Vertebral 135" Tempa Aqua catheter, 125 cm (CORDIS)
3. Filter placement
■ exchanged with 0.014" Bare wire, 315 cm (ABBOTT VASCULAR)
■ Emboshield filter 4/7 mm embolic protection system (ABBOTT VASCULAR)
4. Athrectomy and thrombectomy, if embolization occurs
■ Jet stream Pathway rotational athrectomy 2.4/3.4 (BOSTON SCIENTIFIC)
■ PENUMBRA aspiration thrombectomy (PENUMBRA)
5. PTA and stenting on indication
■ IN-PACT drug coated balloons 6.0/120 mm (MEDTRONIC)
■ SUPERA stenting 5.5/150 mm (ABBOTT VASCULAR)
11
Tuesday, 17:40 – 18:00 Live from Leipzig Case 09 – LEI 06: male, 73 years, (S-W)
Calcified popliteal artery occlusion
Operators: S. Bräunlich, Y. Bausback
Clinical data: Critical limb ischemia with ulceration lateral foot right
Severe claudication right since years
ABI right 0.34, Rutherford class 5
Thrombendartherectomy right groin 2013
Risk factors:
Diabetes mellitus type 2, art. hypertension, former smoker
Angiography:
Severely calcified distal SFA and Apop – occlusion right
Procedural
steps
■ 6F 55 cm sheath (COOK)
■ Stiff angled Radiofocus guidewire 0.035”, 260cm (TERUMO)
■ Armada 35 balloon 4.0/120mm (ABBOTT)
In case of failure form antegrade:
■ Retrograde approach vie peroneal or posterior tibial artery
3.PTA
■ Armada 5/40 and 6/40 mm balloon (ABBOTT)
■ Conquest High Pressure Balloon (C.R.BARD)
4. Stenting
■ Supera Interwoven Nitinol Stent (ABBOTT)
12
Tuesday, 08:10 – 08:30 Live from Berne Main Arena 2 · Room 2
Case 10 – BER 01: male, 52 years (T-H)
Iliofemoral venous intervention
Operators: N. Kucher, T. Fuss
Present state:
Venous claudication (painfree walking distance 500 m)
Swelling (2 cm plus in thigh circumference) despite compression therapy
No skin changes
No varicose veins
Duplex:
Postthrombotic changes in iliac and femoral veins
CT:
Mechanical compression of the left iliac vein through ostheosynthetic material
Procedural
steps
Tuesday
Clinical data: Iliac vein thrombosis left side in 2013 treated with anticoagulation
Iliac vein thrombosis left side 06/2015
Mechanical compression of the left iliac vein (ostheosynthesis L4/5)
1.Venous access with ultrasound guidance in left popliteal
■ 10F sheath
2. Wire crossage
■ Terumo 0.035 stiff angled
3. Phlebography, IVUS
4.Predilatation
■ Atlas Balloon 14 mm (Bard)
5.Implantation of dedicated Iliac vein stents
■ Sinus-Obliquus 14–16 mm (OptiMed),
■ Sinus-XL Flex 14–16 mm (OptiMed), or
■ Vici 14–16 mm (Veniti)
6. High-pressure postdilation of stents
13
Tuesday, 09:10 – 09:20 Live from Galway Main Arena 2 · Room 2
Case 11 – GAL 01: female, 41 years (N-W)
Chronic left iliac reconstruction
Operators: I. Davidson, G. O’Sullivan
Present state: First DVT in 2009 – just post partum – see CT
Waited 9 months, attempted endovascular reconstruction – failed.
Has had 2 more children.
Symptoms: weight gain, 50 m claudication up hill, heavy dead tired leg.
Risk factors: Underlying May Thurner
Procedural
steps
1.Prep
■ R IJV; left groin and thigh; right groin
2.UltraSound (SIEMENS) guided access to left profunda
and RIJV (COOK Micropuncture set)
■ 10F sheath (COOK) to neck; 5F sheath BRITE TIP
(CORDIS) left PFV
■ 5000u IV Heparin
■ Triforce (COOK MEDICAL) to gain access to
and attempt to cross left iliac venous occlusion
3.Wires
■ Hydrophilic 0.035" wire (MERIT MEDICAL)/stiff
hydrophilic 0.035" wire (MERIT MEDICAL)/
Roadrunner 0.035" wire (COOK MEDICAL)
■ Asahi Astante 0.014" 30g tip CTO wire with
back up 2.5 mm balloon
■ Possibly snare (AndraSnare, ANDRAMED) if needed/
Lunderquist 0.035" wire 260 cm (COOK MEDICAL)
once across
4.Balloon predilatation
■ BARD Atlas 16/14 mm
to minimum 16 atm x 30s each zone
5.Stenting
■ BARD Venovo 16/14/12 from low IVC down
to either low CFV or else into PFV
6.Postdilatation
■ BARD Atlas again to same pressures and diameters
■ IVUS (Volcano/PHILIPS) to confirm stent apposition
and identify any intra-luminal debris
■ Cone Beam CTV (SIEMENS) to confirm stent apposition
7.Aftercare
■ Thigh high class 2 compression stockings (JOBST)
■ Pneumatic compression boots (COVIDIEN/MEDTRONIC) x 24h until US performed
■ Colour doppler US day 1 post op CTV direct at 6/52
14
Case 12 – LEI 07: male, 62 years (PMC-L)
Acute early reocclusion left SFA after PTA/Stent
Operators: S. Bräunlich, Y. Bausback
Tuesday
Clinical data: Severe claudication left calf, walking capacity 120-150 meters
ABI left 0.63
PTA and stenting of a short distal SFA-stenosis left 11/2015 elsewhere
Acute thrombosis of the SFA
Risk factors: CAD, MI 2003
Art. hypertension, diabetes mellitus type 2, former smoker
PTA / stent SFA-Stenosis left 11/2015
Procedural
steps
Acute occlusion early after PTA
■ IMA-diagnostic 5F-catheter (CORDIS / CARDINAL HEALTH)
■ 0.035" angled soft Radiofocus glidewire, 190 cm (TERUMO)
■ 0.035" SupraCore guidewire, 190 cm (ABBOOTT)
■ 8F Balkin Up&Over Sheath, 40 cm (COOK)
2.Passage of the occlusion and percutaneous thrombectomy
■ 0.018" Connect Guidewire 300cm (ABBOTT)
■ Exchange to Rotarex guidewire (STRAUB MEDICAL)
■ 8F Rotarex Thrombectomy Catheter (STRAUB MEDICAL)
3.PTA with DCBs
■ In.Pact Pacific 5.0/120 mm (MEDTRONIC)
4.Stenting on indication
■ Epic Selfexpanding Nitinol-Stent (BOSTON SCIENTIFIC)
15
Tuesday, 10:20 – 10:50 Live from Leipzig
Case 13 – LEI 08: male, 70 years (D-K)
In-stent reocclusion left SFA
Operators: M. Ulrich, M. Moche
Clinical data: Severe claudication left calf, walking-capacity 150-200 meters since 9/2015
ABI left 0,67
Stenting left SFA 08/2014
Stenting iliac arteries left 2003 and right 12/2015
CAD with PTCA 2003
Risk factors:
Art. hypertension, current smoker
Angiography:
During PTA right iliac 12/2015: In-stent reocclusion left SFA
Procedural
steps
■ IMA diagnostic catheter, 5F (CORDIS / CARDINAL HEALTH)
■ 0.035" SupraCore 190 cm Guidewire (ABBOTT)
2. Passage of the in-stent occlusion left SFA
■ Judkins Right 5F-catheter (CORDIS / CARDINAL HEALTH)
■ 0.035" Radiofocus angled stiff glidewire, 260 cm (TERUMO)
■ Exchange to 0.018" Guidewire (STRAUB MEDICAL)
3. Catheter-thrombectomy
■ 8F Rotarex (STRAUB-MEDICAL)
4. PTA with drug-coated balloons
■ Lutonix DCBs (C.R.BARD)
16
Tuesday, 11:00 – 11:15 and 12:00 – 12:15 Live from Berne Main Arena 2 · Room 2
Case 14 – BER 02: male, 48 years (J-Z)
Tuesday
Medical history: Ilio-femoro-popliteal thrombosis 1986 after severe car accident with polytrauma
Permanent neurocognitive deficits
Ongoing anticoagulation therapy
Risk factors: Chronic venous insufficiency left leg with: venous claudication, varicose veins,
hyperpigmentation, leg swelling
Villalta-Score: 6 points
CT: Procedural
steps
May Thurner compression of the left common iliac vein
1.Venous access with ultrasound guidance in left popliteal (10F sheath)
2. Wire crossage
4. Predilation
5.Implantation of dedicated Iliac vein stents
■ Sinus-Obliquus 14–16 mm (OptiMed),
■ Sinus-XL Flex 14–16 mm (OptiMed), or
■ Vici 14–16 mm (Veniti)
17
Tuesday, 11:15 – 11:30 and 12:15 – 12:30 Live from Galway Main Arena 2 · Room 2
Case 15 – GAL 02: male, 74 years (D-B)
May Thurner treatment
Operators: I. Davidson, G. O’Sullivan
Clinical data: Background multiple myeloma
On chemotherapy (Pomalidomide) which is pro-thrombotic
Extensive DVT December 2015 treated with catheter directed thrombolysis
Good result; finished 25/12; he went home before stenting
Risk factors: Multiple myeloma, pomalidomide, underlying May Thurner
Procedural
steps
1.R IJV access
■ US (SIEMENS) 10F sheath
2.Cross lesion
■ IVUS (Volcano/PHILIPS) to delineate anatomy
3.Predilatation
■ BARD Atlas 16 mm to >16 atm for > 16 s
4.Stenting – choice of
■ Optimed Sinus Venous/Obliquus 16 mm
■ Wallstent 16 mm/COOK Zilver Vena 16 mm
■ Veniti Vici 16 mm
5.Postdilatation
■ to 16 mm to >16 atm for > 16 s
6.Post stent IVUS
7.Immidiately mobilise and home
18
Tuesday, 13:30 – 15:00 Live from Berne
Case 16 – BER 03: female, 38 years (A-M)
Tuesday
Clinical data: Past medical history: No personal or familiy history of DVT
Previously healthy
Chronic venous insufficiency left leg with:
Venous claudication (walking distance 600 m)
Leg swelling (thigh 7 cm plus)
No varicose veins or skin changes
Duplex/CT: Stenosis of the external iliac vein left side
Procedural
steps
1.Venous access with ultrasound guidance
in left popliteal (10F sheath)
2. Wire crossage
4. Predilation
5.Implantation of dedicated iliac vein stents
■ Sinus-XL Flex 14 mm (OptiMed), or
■ Vici 14 mm (Veniti)
19
Tuesday, 13:30 – 15:00 Live from Galway Case 17 – GAL 03: female, 40 years (E-S)
Failed varicose vein treatment; pelvic vein source
Operators: G. O’Sullivan, I. Davidson
Clinical data: Three children, haemorrhoids and vulval varicosities
during pregnancy
Varicose veins left posterior thigh and calf
treated by foam and RFA in June 2015
At clinical follow-up 6 weeks satisfactory
At 6 months ALL recurred
Imaging: Mildly enlarged L ovarian vein
Tight left common iliac vein compression on MRV
CDUS – large varicose veins posterior thigh and
upper calf – extend close to introitus
Procedural
steps
1.GA
■ R I JV access
■ Selective catheterisation of L ovarian vein:
both internal iliac veins; possibly right ovarian V
■
■
oils (COOK MEDICAL) +/– EMBA medical "hourglass"
C
Foam (Sclerovein 3% diluted 3:1 with air)
2. IVUS to examine is iliac vein compression syndrome real
3. If IVCS suggests it is real the predilate to 16 mm BARD Atlas
4. Stenting if IVCS is real
■ COOK Zilver Vena 16 mm/VENITI Vici 16 mm/Wallstent 16 mm
■ OPTIMED Sinus Venous/Obliquus 16 mm
5. Postdilate to 16 mm
6. Foam sclerotherapy and RFA to thigh veins
7. Transvaginal US to confirm ablationof all veins at 6/52
20
Tuesday, 15:20 – 15:45 Live from Cotignola
Case 18 – COT 02: male 79 years (GAD)
Asymptomatic severe right ICA stenosis
Operators: F. Castriota, A. Micari
Tuesday
Clinical data: 2008 Right subclavian artery PTA
2009 Left renal artery PTA
2010 Right and left Iliac arteries PTA
2013 Right and left SFAs PTA
November 2015: severe right leg claudication → Right CFA, SFA and popliteal artery PT
Risk factors: Diabetes, smoking, hypertension
Asymptomatic for neurological deficits
DUS: severe (90%) right ICA stenosis (vel. 354 cm/sec).
Procedural
steps
1.Left femoral approach
(opportunity of radial approach to be still evaluated)
2. MoMa positioning for proximal cerebral protection (MEDTRONIC)
3. Wire crossing during endovascular clamping
4. Direct stenting with a double mesh new generation stent (Roadsaver; TERUMO)
5.Post dilation (Falcon Grand Balloon; MEDTRONIC)
6. Debris (if any) aspiration and declamping
21
Tuesday, 16:05 – 16:30 Live from Cotignola
Case 19 – COT 03: male 75 years (A-M)
Symptomatic left ICA stenosis
Clinical data: One episode of Amaurosis fugax of left eye in January 2015
Risk factors:
Smoking, hypertension
No evidence of neurological deficits
DUS: severe (80%) stenosis of left internal carotid artery (PSV 2,7 m/sec)
Bovine Arch
Severe LICA stenosis
(> 80%)
Procedural
steps
1.Right radial approach
2. Distal filter protection
n Spider EPD (MEDTRONIC)
3. Left internal carotid stenting
n Roadsaver Double-Mesh-Stent (TERUMO)
4. Postdilatation
n Maverick XI-Balloon (BOSTON SCIENTIFIC)
22
Tuesday, 16:30 – 18:00 Live from Berne
Case 20 – BER 04: female, 52 years (M-B)
Pelvic congestion syndrome
Tuesday
Medical history: Appendectomy and removal of ovarian cyst 1996
Laparoscopic adhesiolysis and tubal sterilisation 2005
Last menstrual cycle 03/2015
Recent gynecologic exam unremarkable
Present state: Left sided abdominal dull pain, lower quadrant since 6 months
The pain is worse during defecation
No pain during or after sexual intercourse or during voiding
Pain dependence on position (no pain during bed rest, worse while standing and sitting)
CT: Prominent left-sided ovarian vein, varicose, parauterine veins
Venography: Refluxing left-sided ovarian vein, no reflux in hypogastric and right ovarian vein
Procedural
steps
1.Venous access in right femoral vein (5F sheath)
2. Cobra 4F diagnostic catheter
3. Selective venography of distal left ovarian vein
4. Foam sclerotherapy of varicose uterine veins
5. Coil embolization of ovarian veins (0.018, 8–12 mm)
23
Tuesday, 16:30 – 18:00 Live from Galway
Case 21 – GAL 04: female, 34 years (C-F)
Acute left leg DVT
Operators: G. O’Sullivan, I. Davidson
Clinical data: Acute onset left leg pain and swelling started 8 days ago
CTPA clear
CTV shows left sided DVT from L CIV to mid thigh
Risk factors: Oral contraceptive pill
Procedural
steps
1.Prone
■ Popliteal venous access (Micropuncture set, COOK)
■ Ascending venography
2.Hydrophilic wire into IVC
■ terumo Glide 180 cm, 0.035"
■ Confirm position in IVC
3.AngioJet Zelante (BSCI)
■ Lyse and wait
■ Pulse spray 20 mg tPa + 180 cc N saline into affected area
4.Wait 20 minutes
■ Use device in thrombectomy mode
■ Alternativ devices Penumbra or Aspirex (STRAUB)
5.Aspirate any adherent thrombus
■ Curved 45 cm 8F Hockey Stick (CORDIS)
6.If Grade 2 lysis or worse
then EKOS drip lysis x 24h (BTG)
7.If Grade 3 SIR lysis
then balloon/stent/ballon as per prior cases
24
Tuesday, 09:36 – 10:15 Live from Berlin Technical Forum · Room 3
Case 22 – BLN 01: female, 59 years, (E-P)
Tripple protection in a high-grade left ICA stenosis
(double filter and micro-mesh stent)
R. Langhoff, A. Behne
Tuesday
Operators: Risk factors: Arterial hypertension (controlled),
hyperlipidemia (LDL 141mg/dl, Chol. 227mg/dl, HDL 49 mg/dl)
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 ICU
25
Tuesday, 10:52 – 11:23 Live from Cotignola Technical Forum · Room 3
Case 23 – COT 04: male 78 years (M-T)
Asymptomatic rapid progression of right ICA stenosis
Operators: A. Micari, F. Castriota
Clinical data: Asymptomatic for cerebrovascular events. Recent successful PTA to left ICA
(December 2015), angiography showed rapid progression of right ICA disease.
Risk factors:
Diabetes, smoking, hypertension
Severe asymptomatic right ICA stenosis
Angiography:
80% right ICA stenosis (progressed from 50% one year ago)
Procedural
steps
1.Right femoral approach
2. MOMA positioning for proximal cerebral protection (MEDTRONIC)
4. Direct stenting with an Xact-Stent (ABBOTT)
5. Postdilation with Maverick XI Balloon (BOSTON SCIENTIFIC)
Left ICA PTA Baseline
Right ICA angiography
26
Final result
Tuesday, 11:45 – 12:30 Live from Berlin Technical Forum · Room 3
Case 24 – BLN 02: male, 69 years, (E-P)
Chronic total occlusion of the right SFA
Operators: R. Langhoff, M. Boral
Risk factors:
Smoker 08/2014
Duplex:
Bilateral chronic total occlusion of the SFA
ABI:
Left 0.62, right 0.69
Procedural
steps
Tuesday
Clinical data: Bilateral chronic total occlusion of the SFA,
cross-over recanalisation of the left SFA in 12/2015
■ Diagnostic 4F glidecath catheter (Terumo)
■ Terumo stiff angled 0.035" wire into left SFA
2. Passage through the occlusion
■ Glidecath catheter (CORDIS/CARDINAL HEALTH) and Terumo stiff angled 0.035" wire
3. Backup-Material
■ Outback elite reentry catheter exchange (Cordis)
4. Correct positioning and orientation
of the nitinol cannula towards the true lumen
and deploy the needle into the lumen,
insert the 0.014 Stabilizer wire into the true lumen
5. Predilation
■ Monorail Saber 4 x 150 mm balloon
6. Stent implantation
■ Two Smart Flex stents 6 x 200 and 6 x 120 mm (CORDIS/CARDINAL HEALTH)
■ Exoseal (CORDIS/CARDINAL HEALTH)
27
Tuesday, 13:30 – 15:00 Live from New York Technical Forum · Room 3
Case 25 – NYC 02: female, 65 years, (D-J)
In-stent occlusion with stent fractures RSFA
Operators: P. Krishnan, K. Gujja, V. Kapur
Clinical data: Subacute onset R leg pain 2 to 3 months, Rutherford Class II, Category III
US Duplex showed instent occlusion of RSFA
Failed R Fem pop bypass, multiple PTA and stenting of RSFA
at outside hospital, failed revascularization of RSFA due to stent fracture
Risk factors:Hypertension, dyslipidemia, coronary artery disease,
polycythemia vera (ongoing work up)
Procedural
steps
1.Left Common femoral access and up and over
■ 7F Pinnacle destination sheath 45 cm, up and over (TERUMO)
■ If necessary, R pedal posterior tibial retrograde access (4F COOK sheath)
and direct stent access
2. Intra-luminal approach
■ 0.014" 4 Fr Viance catheter, 150 cm (MEDTRONIC)
■ 0.038" Vertip catheter, 125 cm (CORDIS/CARDINAL HEALTH)
■ 0.014" Confianza wire, 300 cm (ABBOTT VASCULAR)
3. Thrombectomy
■ Angiojet Rheolytic aspiration thrombectomy (BOSTON SCIENTIFIC) or
■ Penumbra aspiration thrombectomy (PENUMBRA)
4. Filter placement
■ exchanged with 0.014/Bare wire, 315 cm (ABBOTT VASCULAR)
■ Emboshield filter 4/7 mm embolic protection system (ABBOTT VASCULAR)
5. PTA and Stenting as indicated
■ INPACT drug coated balloons 6.0/120 mm (MEDTRONIC)
■ Supera stenting 5.5/100 mm (ABBOTT VASCULAR)
28
Tuesday, 13:30 – 15:00 Live from Dendermonde Technical Forum · Room 3
Case 26 – DEN 02
Tuesday
For case information
please download the LINC 2016 App
or visit the LINC 2016 website.
29
Tuesday, 15:10 – 15:40 Live from Berlin Case 27 – BLN 03: male, 75 years ( R-D)
SFA combination therapy
Operators: R. Langhoff , A. Behne
Clinical data: PAD Rutherford 3 left calf,
PTA and stenting right SFA occlusion 1/2016
Risk factors:Arterial hypertension, hyperlipidemia
ABI:Right 0.75, left 0.63
Procedural
steps
■ 6F cross over sheath ( Fortress, Biotronik)
2. Recanalisation left SFA occlusion
■ 35" Terumo Stiff wire and glidecath catheter
3. PTA
■ Passeo 18 (Biotronik)
4. SFA stenting
■ Pulsar 18 (Biotronik)
5. PTA
■ DEB Passeo 18 Lux
■ Angioseal 6F if possible
30
Technical Forum · Room 3
Tuesday, 15:50 – 16:20 Live from Dendermonde Technical Forum · Room 3
Case 28 – DEN 03: male, 83 years ( F-P)
TASC C SFA lesion right
Operators: K. Deloose, L. Maene
Procedural
steps
Tuesday
Clinical data: History: 2007 CAS Right
Since 3 months bilateral claudication left > right after <100 m (Rutherford 3)
Good CFA pulses
No popliteal/distal pulses
Risk factors:Diabetes mellitus type 2, arterial hypertension, hypercholesterolemia
1.Left CFA access
■ Glidewire 0.035" (Terumo)
■ RIM Catheter (Cook Medical)
■ Fortress 6F, 45 cm (Biotronik)
2. Recanalisation
■ Advantage 0.018", 260 cm (Cook Medical)
■ CXI Catheter 0.018", 150 cm (Cook Medical)
3. Predilatation
■ Passeo 18 Lux 6 mm (Biotronik)
4. Stenting
■ Pulsar 18 6 mm (Biotronik)
5. Postdilatation
■ Passeo 18 6 mm (Biotronik)
6. GE Healthcare
■ Vessel Assist - Center Line Tracking
31
Tuesday, 16:30 – 18:00 Live from Cotignola Technical Forum · Room 3
Case 29 – COT 05: male 81 years (A-M)
Rapid progression of asymptomatic left ICA stenosis
Clinical data: History of paroxismal atrial fibrillation
July 2015: DUS (primary prevention)→ 70% left ICA stenosis (VPS 1.8 m/sec)
Risk factors:Hypertension, hypercholesterolaemia
Asymptomatic for neurological deficits
Duplex:80% left ICA stenosis (VPS 3.4 m/sec)
Procedural
steps
1.Right femoral approach
2. MoMa positioning for proximal cerebral protection (MEDTRONIC)
4. Direct stenting with a Carotid Wallstent (BOSTON SCIENTIFIC)
5. Postdilatation with a Maverick XI Balloon (BOSTON SCIENTIFIC)
32
Tuesday, 16:30 – 18:00 Live from Leipzig Technical Forum · Room 3
Case 30 – LEI 09: male, 56 years (L-F)
Recurrent stenosis left common carotid artery
Procedural
steps
Tuesday
Clinical data: Recurrent stenosis left common carotid artery at the proximal anastomosis
of a prosthesis-interposition left CCA after radical neck dissection
of a parotid cancer left with infiltration of the CCA and radiation therapy 2010
Fogarty-thrombectomy left CCA and stenting left CCA / ICA 2015
Minor stroke 2015
Risk factors:Facial nerve paresis left since 2015
Minor paresis right arm since 2015
Dysarthria
Former smoker, arterial hypertention, diabetes mellitus type II
Duplex:High grade recurrent stenosis left proximal common carotid artery
Angiography:90% proximal CCA-stenosis and 70% recurrent stenosis distal to the ICA-stent
1.Right groin retrograde approach
■ Judkins-Right 8F-guiding-catheter (CORDIS)
2. Placement of a filter
■ Wirion protection device (ALLIUM MEDICAL)
3. Predilatation, stenting and postdilatation
■ 3.5/20 mm AngioSculpt RX scoring-balloon (SPECTRANETICS)
■ 9.0 or 10/30 mm CGuard carotid embolic prevention system (InspireMD/PENUMBRA)
■ 7.0/20 mm Sterling RX-balloon (BOSTON SCIENTIFIC)
33
Tuesday, 13:51 – 14:14 Live from Berlin Global Expert Exchange Forum · Room 5
Case 31 – BRL 04: male, 74 years, (M-S)
DES in a CLI patient with BTK Revascularisation
Operators: R. Langhoff, N. Jabs
Clinical data: Bilateral severe claudication left > right since years,
recently deterioration of walking distance and lesion
at the the dorsal side of the 2nd toe
Risk factors:
Hyperlipidemia, former smoker, controlled hypertension,
MRA with BTK vessel occlusions
ABI at rest: 0.5 left, 0.64 right
ABI at rest:
Left 0.5, right 0.64
Procedural
steps
1.Antegrade access left CFA
■ 4F Fortress sheath (Biotronik)
2. Approaching the lesion
■ 0.014" wire approach, Advantage wire (Terumo)
■ Backup with CXI support catheter (COOK)
3. PTA and stenting of the occluded tibioperoneal trunc
■ 3.0 x 38 mm Cr8 BTK Stent (ALVIMEDICA)
4. Recanalisation of the anterior tibial artery
■ Primary PTA 2.5 x 200 mm Coyote balloon (Boston Scientific)
34
Tuesday, 15:31 – 15:57 Live from Leipzig Global Expert Exchange Forum · Room 5
Case 32 – LEI 10: male, 67 years, (P-S)
Chronic total occlusion of the mid SFA right
Risk factors:
Angiography:
Moderately calcified mid SFA occlusion right
Procedural
steps
Tuesday
Clinical data: Severe claudication right calf since years, walking capacity 150 meters
ABI right 0.67, Rutherford class 3
Thromboendarterectomy left groin 2013
■ Stiff angled Radiofocus guidewire 0.035”, 260 cm (TERUMO)
■ Armada 35 balloon 4.0/80 mm (ABBOTT)
3. Direct stenting
■ NitiDES Drug-Eluting Stent (ALVIMEDICA)
35
36
L e i p z i g
C o u r s e
2 0 1 6
Wednesday
Wednesday,
January 27, 2016
37
Wednesday, 08:29–09:00 Live from Berlin Main Arena 1 · Room 1
Case 33 – BLN 05: male, 66 years (N-R)
High grade calcification and stenosis of the right common femoral artery
Operators: R. Langhoff, A. Behne
Clinical data: PAD Rutherford 3 right calf,
former Stenting of the left common iliac and external iliac artery,
formerP TA and Stenting left SFA
ABI:
Right 0.73; left 0.91
Risk factors:
Hypercholesterinemia ( Chol.282 mg/dl, LDL 174, HDL 55)
Arterial Hypertension
Procedural
steps
1. Transfemoral retrograde approach
■ 7F cross over sheath (Terumo)
■ 35" terumo stiff guidewire
2. Embolic protection
■ Filter Wire EZ (BOSTON SCIENTIFIC)
3. Artherectomy
■ Jetstream XC 7F , 120 cm (BOSTON SCIENTIFIC/BAYER)
4. PTA
■ DEB Ranger 5 x 60 and 6 x 40 mm (BOSTON SCIENTIFIC)
■ Starclose 6F
38
Wednesday, 09:51 – 10:21 Live from Berne Main Arena 1 · Room 1
Case 34 – BER 05: male, 34 years (R-V)
Complex intervention of IVC and iliac veins
Clinical data: Past medical history:
Thrombosis of IVC and bilateral Iliac veins 08/2013 treated with anticoagulation
Varicocele, hemorrhoids
Thrombophilia testing negative
Failed endovascular recanalisation attempts in 2015 in two tertiary care hospital
Bilateral venous claudication
Lumbar pain, bilateral swelling despite compression therapy, varicose veins
Currently no anticoagulation therapy
CT: postthrombotic IVC, large hemiazygos vein,
Failed endovascular treatment
Wednesday
Present state:
Procedural
steps
1.Bilateral common
femoral vein access,
right jugular vein
access with ultrasound
guidance (10F sheath)
2. Wire crossage
4. Predilation
■ Atlas Balloon 14–18 mm (Bard)
5. Implantation of dedicated Iliac vein stents
over Terumo stiff angled wire 0.035":
■ IVC stents: Sinus XL 22 mm (OptiMed),
■ Kissing Iliac vein stents: Sinus-XL Flex 14–16 mm (OptiMed)
6. High-pressure post-dilation of stents
■ Atlas balloon 14–18 mm (Bard)
39
Wednesday, 11:20 – 11:35 Live from Leipzig Main Arena 1 · Room 1
Case 35 – LEI 11: male, 50 years (R-D)
Reocclusion right SFA
Operators: M. Ulrich, A. Schmidt
Clinical data: Severe claudication right calf, painfree walking capacity 50 meters
Rutherford class 3
ABI right 0.63
PTA left SFA 12/2015, PTA right SFA with DCBs 12/2012
Risk factors:
Procedural
steps
Art. hypertension, current smoker
1. Left groin retrograde and cross-over approach
■ 7F–40 cm Balkin Up&Over Sheath
2. Guidewire passage
■ 0.035" stiff angled Radiofocus guidewire, 260 cm (TERUMO)
■ 0.035" Seeker Support-catheter, 135 cm (BARD)
In case of failure to redirect the guidewire back into the true lumen
retrograde approach via the distal SFA:
■ 21 Gauge 9 cm puncture needle (COOK)
■ 0.018" V-18 Control guidewire 90 cm (BOSTON SCIENTIFIC)
3. PTA and stenting
■ Armada 35 5.0/120mm (ABBOTT)
■ 6.0/250 mm Viabahn (W.L.GORE)
■ 7.0/80 mm Gore Tigris Stent across the collateral distal to the occlusion (W.L.GORE)
40
Wednesday, 11:50 – 12:10 Live from Dendermonde Main Arena 1 · Room 1
Case 36 – DEN 04: male, 61 years (B-F)
In-stent reocclusion right SFA
Operators: K. Deloose, J. Callaert
Clinical data: History: 2001 PTAS bilateral SFA, 2011 PTA ATI left, 2011 PTA ISR
Stenosis right SFA, 2014 DCB right SFA ISR + poplitea
Present state: Recurrent claudication < 100m (Rutherford 3)
CT Angio Lower Limb
Procedural
steps
Diabetes mellitus, hypercholesterolemia, smoking
1. Left CFA Access
■ 0.035" Glide wire (Terumo)
■ RIM Catheter (Cook Medical)
Wednesday
Risk factors:
2. Recanalization
■ CXI Catheter 0.018", 150 cm (Cook Medical)
3. Predilatation
■ Armada 0.018", 5 or 6 mm (Abbott Vascular)
4. Stenting
■ Viabahn 5 or 6 mm, 250 mm (Gore)
5. Postdilatation
■ Armada 0.018", 5 or 6 mm (ABBOTT)
6. Plan B
Direct Stent Puncture right SFA +
Retrograde/Bidirectional Recanalization
41
Wednesday, 13:53 – 14:39 Live from Leipzig Case 37 – LEI 12: male, 74 years (G-W)
Chronic SFA-Occlusion right
Clinical data: Severe claudication right calf, Rutherford class 3
ABI right 0.62
Angiography during PTCA 11/2015:
Long SFA-occlusion right and popliteal artery stenosis right
Risk factors:
CAD with NSTEMI 11/2015 and PTCA RCX
Moderate aortic valve stenosis
Former smoker, art. hypertension, diabetes mellitus Type 2
Procedural
steps
■ 6F-40cm Balkin Up&Over Sheath (COOK)
2. Passage of the CTO
■ 0.035" Radiofocus glidewire, stiff, angled,
260 cm (TERUMO)
■ 0.035" Seeker support-catheter, 135 cm
(BARD)
■ Exchange to a 0.018" SteelCore guidewire
300 cm (ABBOTT)
3. PTA
■ 5.0/250mm VascuTrak Scoring Ballon (BARD)
■ Lutonix 6.0/150mm Drug-Coated Balloon
(BARD)
■ LifeStent (BARD)
42
Case 38 – LEI 13: male, 75 years, (K-G)
BTK long tibial occlusion
Clinical data: Critical limb ischemia right forefoot, Rutherford 5
Diabetic foot with ulceration Dig 4-5 and restpain
Failed recanalization attempt left BTK 1/2016 elsewhere
Diabetes mellitus type 2, art. hypertension, former smoker, hyperlipidemia
CAD, MI 2013, ischemic cardiomyopathy with EF 50%
Chronic renal insufficiency with GFR 75 ml/min
Angiography:
Left: Total occlusion of the anterior and posterior tibial artery
High grade stenosis of the peroneal artery
Wednesday
Risk factors:
Procedural
steps
1. 1.Left antegrade approach
■ 5F-50 cm sheath (COOK)
2. 2.Passage of the anterior tibial artery occlusion
■ PT2 0014” Guidewire, 300cm (BOSTON SCIENTIFIC)
■ Seeker Support-catheter 0.018” 90cm (C.R.BARD)
In case of failure to pass from antegrade:
retrograde approach via the DPA
■ 2.9F sheath (pedal puncture set) (COOK)
3. Predilatation and treatment with DCBs
■ VascuTrak 2.5/250 mm Scoring Balloon (C.R.BARD)
■ Lutonix 2.5/150 and 3.0/150 mm DCB (C.R.BARD)
43
Wednesday, 15:13 – 15:39 Live from Kingsport Case 39 – KPT 01: male, 81 years
High grade stenosis of the right internal carotid
Operators: C. Metzger, R. Sakhuja, M. Aziz
Clinical data: CAD w 2 DES LAD 10/14, COPD
FEV1 0.9, NIDDM
Recent R hemispheric TIA X2 with L arm and leg weakness
R amarousis fugax 6 months ago
Risk factors:
Htn, dyslipidemia, former smoker
CDU: R PSV 447 cm/sec, EDV 179 cm/sec, ICA/CCA 6
CTA (shown): ≥ 80% high RICA stenosis
Procedural 1. 9F MoMa proximal embolic protection (Medtronic)
steps
2. Predilatation with 4.0/30mm Quantum (Boston Scientific)
3. Implantaiton of a 8-10/40 Xact Stent (ABBOTT)
4. Postdilation with 5/20 Quantum (Boston Scientific)
44
Wednesday, 15:55 – 16:22 Live from Kingsport Main Arena 1 · Room 1
Case 40 – KPT 02: male, 62 years
High grade stenosis of the right petrous internal carotid
Clinical data: CAD: 5 DES RCA, 2 DES LAD @ outside hospital
PVD: R fem-pop 1999, 100% graft/SFA/pop
60+ pack/year tobacco/COPD, D/C'd 2013
NIDDM (HbA1c 12), Htn, dyslipidemia
Multiple episodes vertebrobasilar sx's, L vert 99%, R vert 80 prox,
99–100 distal, S/P L vertrebral PTA & stent
Multiple episodes R hemispheric TIA's, patient's TIA resolved, recurrent sx's 12/15
Risk factors:
Htn, dyslipidemia, agressive smoker (60+ py)
Procedural
steps
Wednesday
CT/Angio:CTA 95% intracranial RICA petrous lesion
s/p PTA R IC petrous lesion with "submaximal angioplasty technique" 5/15
CTA 95% restenosis
Angios: L vert stent OK, R petrous ICA 95%
1. MOMA-Cerebral Protection (Medtronic) or 8-9F Stryker Balloon Guide (Stryker)
2. Synchro-2 guidewire (Stryker) with Excelsior 2 Transit Catheter (Stryker)
3. PTA with 2.25 x 8 mm Trek Balloon (abbott)
4. DES Implantation Xience Alpine 3/12 mm (abbott)
PTA
IVUS
Stent
45
Wednesday, 16:50 – 17:10 Live from Leipzig Case 41 – LEI 14: male, 73 years (P-S)
Diffuse restenosis left SFA
Operators: S. Bräunlich, M. Ulrich
Clinical data: Severe claudication left calf, walking capacity 200-300 meters
Rutherford class 3, ABI left 0.68
PTA with plane balloon angioplasty left 7/2015
(POBA-arm of a DCB randomized controlled trial)
PTA right SFA 1/2016
CAD
Minor stroke without residual symptoms 2012
Risk factors:
Procedural
steps
Art. hypertension, former smoker
Angiography during PTA right SFA: diffuse restenosis left SFA
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)
2. Guidewire-passage and preparation of the lesion
■ 0.018" SteelCore Guidewire, 300 cm (ABBOTT)
■ FLEX Plaque Modification Catheter (VENTURE MED GROUP)
3. PTA and stenting on indication
■ Luminor DCB 5.0/120 mm (iVascular)
■ VascuFlex Multi-LOC (B.BRAUN)
46
Left SFA befor and after POBA 7/2015
Restenosis left SFA 1/2016
Wednesday, 17:35 – 18:00 Live from Kingsport Main Arena 1 · Room 1
Case 42 – KPT 03: active male, 60 years
CTO of the right SFA
Clinical data: L subclavian AND LICA artery occlusions
Severe lifestyle-limiting R claudication @ 50'
Risk factors: Current smoker, HTN, dyslipidemia
ABI: Right 0.50 → 0.16
Procedural
steps
≈ steep iliac bifurcation, R SFA/popliteal CTO
1.Contralateral access
■ 7F Ansel cross-over sheath (COOK)
cross CTO (tibial access prn)
■ QUickCross catheter (Spectranetics)
■ 0.035" Glidewire (Terumo)
Wednesday
CTA: 2.PTA and DCB R SFA/popliteal
■ Armada Balloon (Abbott)
■ Lutonix DCB (Bard)
3.If dissections after DCB, provisional placement of nitinol "tacks"
(IntactSolutions)
47
Wednesday, 08:28 – 08:52 Live from Münster Case 43 – MUN 01: male, 72 years (K-V)
EVAR with Sandwich left acc. RA
Operators: B. Gehringhoff, M. Bosiers
Clinical data: Juxtarenal aneurysm 59 mm max. below a left acc. RA
Risk factors:CAD, art. hypertension, hypertensive heart disease, LE 12/15
Procedural
steps
48
■
Percutanous approach both groins Prostar XL (Abbott).
■
Placement of 14 F sheaths (COOK).
■
■
■
■
Placement of Endurant bifurcated endograft (Medtronic)
just below the LRA.
annulation of the lower left renal artery
C
and placement of the sandwich graft (Gore-Viabahn).
Extension of the the aortic endograft with a Endurant-tubegraft
(Medtronic) in order to complete the sandwich-repair.
Closure of the groins.
Wednesday, 09:40 – 10:05 and 10:25 – 10:50 Live from Leipzig Main Arena 2 · Room 2
Case 44 – LEI 15: male, (R-E)
Abdominal aortic aneurysm
Operators: A. Schmidt, D. Branzan
Clinical data: Incidental finding of an eccentric AAA, 5.3 cm diameter
Wednesday
Risk factors: CAD with NSTEMI 10/2015, PTCA LAD
Chronic renal insufficiency (GFR 72 ml/min)
Art. hypertention, former smoker
53 mm
Procedural
steps
1.Percutaneous access both groins
in local anaesthesia
■ 5F-10 cm Radifocus-sheaths (TERUMO)
■ 0.035" SupraCore guidewire 190 m (ABBOTT)
■ Preloading of 2 Proglide-systems per groin
(ABBOTT)
■ 0.035" Lunderquist 260 cm guidewires
bilateral (COOK)
2. Graft implantation
■ Implantation of the Altura Stentgraft system and extension
to the hypogastric artery bilateral (LOMBARD MEDICAL)
3. Postdilatation of the whole graft
■ Exchange to 12F-12 cm sheath bilateral (COOK)
■ Reliant balloons both sides (MEDTRONIC)
49
Wednesday, 11:31–12:04 Live from Münster Main Arena 2 · Room 2
Case 45 – MUN 02: male 64 years (H-H)
Endovascular aortic repair of an abdominal aneurysm
Operators: B. Gehringhoff, M. Bosiers
Clinical data: 66 mm rapid growing AAA
Risk factors: Procedural
steps
Hypertension, obesity, hypercholesterinemia
Anxiety disorder Krea 0,9 mg/dl
50
■
■
■
■
■
■
■
■
■
■
Percutanous approach both groins
rostar XL (Abbott)
P
14F sheath (COOK)
lacement of a pigtail catheter via the left groin
P
Lunderquist wire right side
Placement of the main body through the right side
directly below the renals - Treovance-Endograft (BOLTON-MEDICAL)
Probing and positioning of the iliac limb extension contralateral
Ipsilateral positioning of the iliac endograft
Postballooning
Final angiography
Closing access with Prostar (preclose technique)
Wednesday, 12:30 – 13:30 Live from Berne
Case 46 – BER 06: male, 79 years (F-L)
Percutaneous EVAR of infrarenal AAA under local anaesthesia
Operators: D.D. Do, V. Makaloski
Clinical data: Asymptomatic infrarenal AAA with progressively increasing diameter
Femorotibial bypass on the right side 2006
Lower extremity chronic venous disorders CEAP C4 on both sides
PTCA 2006
Wednesday
Risk factors: Type 2 diabetes, arterial hypertension, hyperlipidemia,
65-pack-year cigarette smoking history
CT scan: Axial computed tomography showing partially thrombosed AAA of 5.8mm in diameter (left).
CT angiography with MIP reconstruction showing long infrarenal proximal neck with accessory right renal artery (right)
Procedural
steps
1. Percutaneous femoral access in both groins
■ Local anaesthesia, retrograde puncture of the CFA on both sides
■ 0.035" Radiofocus M stiff guidewire, 180 cm (TERUMO)
■ Preclosure of the access sites using ProGlide devices (ABBOTT)
2.Implantation of the INCRAFT®AAA Stent Graft System
(CORDIS, Cardinal Health)
■ the delivery system (14-F OD) with the main body inside up to the
lower accessory right renal artery, deployment of the main body
■ Implantation of the contralateral and then the ipsilateral iliac
stentgraft (12-F OD)
3. Sealing ot the percutaneous access sites in both groins
■ ballon dilatation of the main body and the iliac limbs: Reliant balloon (MEDTRONIC)
■ control angiogram, then withdrawing the delivery system respectively
the 12F sheath
■ advancing and tying the knots using the knot pusher of the ProGlide system
51
Wednesday, 13:37 – 14:00 and 14:28 – 14:53 Live from Heidelberg Main Arena 2 · Room 2
Case 47 – HEI 01: female, 77 years (H. B.)
Fusion imaging in endovascular infrarenal aneurysm repair
Operators: D. Böckler, A. Hyhlik-Dürr, M. Bischoff
Clinical data: Asymptomatic infrarenal aneurysm (50mm), diagnosed in 12/2015
Risk factors: COPD GOLD III
1-vessel coronary artery disease
Hx of smoking (50py)
Hx of art. hypertension
ABI 1.0 palpable pulses
Procedural
steps
1. Percutaneous access both sides
■ Perclose ProGlide (Abbott)
2. Sheath insertion
■ DrySeal sheath (Gore)
3. Fusion Imaging
■ Prototype syngo X Workplace with AAA Guidance software (Siemens)
– Segmentation of the contrasted aorta
– Selection of operative landmarks (Renal artery ostia, hypogastric artery ostia)
– 2D-3D registration
– Fusion imaging overlay
4. Implantation of endoprosthesis
■ Gore C3-Exluder
– Main body: 28/145/14
– Contralateral leg: 16/16/95
5. Completion angiography
6. Contrast enhanced cone beam CT (Dyna CT)
52
Wednesday, 15:10 – 15:40 and 16:00 – 16:30 Live from Leipzig Main Arena 2 · Room 2
Case 48 – LEI 16: male, 67 years (M-F)
Abdominal aortic aneurysm
Operators: A. Schmidt, D. Branzan, M. Moche
Clinical data: Progressive abdominal aortic aneurysm, diameter 5.1 cm
CAD, PTCA 2014
PAOD
Renal insufficiency (GFR 52 ml/min)
Procedural
steps
Pulmonary thromboembolism 10/2015
Arterial hypertension, hyperlipidemia, diabetes mellitus
1.Bifemoral percutaneous approach in local anaesthesia
■ Preclosing with 2 Proglide closure devices both sides (ABBOTT)
2. Guidewire-positioning
■ Lunderquist GW 180 cm (COOK)
Wednesday
Risk factors:
3. Implantation of a bifurcational stentgraft
■ Ovation Stentgraft (TRIVASCULAR/LOMBARD MEDICAL)
Cannulation of the contralateral limb:
■ 5F Amplatz Left diagnostic catheter (CORDIS/CARDINAL HEALTH)
■ 0.035" soft angled short Radiofocus glidewire (TERUMO)
4. PTA
■ proximal seal: Reliant-balloon (MEDTRONIC)
■ Graft-bifurcation: 12/40 mm Admiral balloon (MEDTRONIC)
53
Wednesday, 16:40 – 17:02 and 17:19 – 17:41 Live from Heidelberg Main Arena 2 · Room 2
Case 49 – HEI 02: male, 73 years (G-K)
Asymptomatic aortoiliac aneurysmal disease
Operators: D. Böckler, A. Hyhlik-Dürr, M. Bischoff
Clinical data: Small AAA 31 mm, left common iliac artery 31 mm
and left thrombosed internal iliac artery aneurysm 38 mm
Diagnosed in 9/2105 in an external institution, asymptomatic status
Ascending aneurysm (46 mm)
Risk factors:
Ectatic infrarenal aorta (31 mm)
Ectatic popliteal arteries (right 13 mm:, left: 14 mm)
Hx of smoking (40 py)
Hx of art. hypertension
ABI 1,0 both sides with palpable pulses
Procedural
steps
■
■
■
■
■
■
■
54
Ultrasound guided percutaneous access
■ Perclose ProGlide (Abbott)
Sheath insertion
Wire change (guidewire - stiff wire)
DrySeal sheath (Gore)
ngiography and Fusion Imaging
A
Prototype syngo X Workplace with AAA Guidance software (Siemens)
Implantation of endoprosthesis
(Gore Excluder Leg Endoprosthesis 16/16/135)
Ballooning
■
ompletion angiography
C
Puncture site closure
■
Contrast enhanced cone beam CT (Dyna CT)
■
Case 49B – LEI 17: female 73 years (M-K)
Amplatzer Plug implantation for an Endoleak via subclavian artery
Clinical data: Type II Endoleak after thoracoabdominal Stentgraft via left subclavian artery
Surgical repair of an aneurysm of the ascending aorta 2015
Bypass surgery from right to left common carotid and from left common carotid to
left subclavian artery to prepare a landing-zone for a thoracoabdominal stentgraft
No proximal bending /clipping to occlude the left subclavian artery
Risk factors:
Art. hypertension
Wednesday
Angiography left: Via left brachial artery: large endoleak into the descending thoracic aorta
Procedural
steps
1. Left brachial approach
2.Implantation of an Amplatzer Plug 16 mm (ST JUDE MEDICAL)
into the proximal left subclavian artery
55
Wednesday, 08:16 – 08:42 Live from Leipzig Case 50 – LEI 18: male, 60 years (B-P)
Aneurysm right renal segmental artery
Operators: M. Moche, J. Fuchs
Clinical data: Incidental finding of a 19 x 15mm renal artery aneurysm
CT due to upper abdominal pain
Gastritis 12/2015
Risk factors: Arterial hypertension
Procedural
steps
1. Right groin 4F access
2. Cannulation of the renal artery
■ Judkins Right 4Fr diagnostic catheter
■ Micro-Catheter
3. Coiling of the aneurysm
■ Penumbra detachable coils (PENUMBRA)
56
Wednesday, 09:50–10:10 Recorded case from Münster Technical Forum · Room 3
Case 51 – MUN 03: male, 83 years (H-K)
Persisting Type II Endoleak via AMI with aneurysm enlargement
Operators: A. Schwindt, N. Abu Bakr
Clinical data: EVAR for AAA 2013 with bifurkated stentgraft, initial diameter of AAA 56 mm, in follow-up
CT-angiograms persisting Type II Endoleak via lumbar arteries and inferior mesenteric
artery (IMA). In 2015 enlargement of AAA to 70 mm in maximum axial diameter.
Art. hypertension, former smoker, CHD
Wednesday
Risk factors:
Procedural
steps
1. Left transbrachial approach
■ 6F 70 cm Raabe sheath (Cook) insertion into ostium of superior mesenteric artery
2. Cannulation of middle colic artery
■ 0,035" Glidewire and 4F 120 cm Glidecath (Terumo)
3. Cannulation of IMA and Endoleak
■ 0,014" Choice PT II wire (Boston Scientific)
4. Catheter insertion
■ 0,014" Echelon or 0,010" Marathon microcatheter into Endoleak
and following angiogram
5.Embolisation of Endoleak with alcohol-colymer
■ Onyx 34/34L (Medtronic)
6. After microcatheter removal
final angiogram via IMA and hypogastric artery
to confirm complete Endoleak embolisation
57
Wednesday, 10:40–11:00 Live from Münster Technical Forum · Room 3
Case 52 – MUN 04: male, 63 years (F-D. P.)
Endoleak embolisation of iliac artery aneurysm
after iliac-sidebranch endograft
Operators: A. Schwindt, N. Abu Bakr
Clinical data: 2013 Complex EVAR for aorto-biiliac AAA with Zentih bifurcated endograft and bilateral
Zenith iliac-sidebranch endografts , 2013 embolisation of Type II Endoleak via AMI. In
CT-angiogram aneurysm enlargement of left iliac aneurysm from initially 55mm to 65 mm
and persisting type II EL via left deep circumflex iliac artery.
Risk factors:
Procedural
steps
Arterial hypertension, CHD, RCX-PTCA 2012, hyperlipidemia
1. Access via retrograde left femoral puncture
■ Insertion of 5F 10 cm sheath (Terumo)
2. Cannulation of deep circumflex iliac artery
■ 0,035 Glidewire and 4F 90 cm Glidecath (Terumo)
3. Cannulation of Endoleak
■ 0,014 Choice PT II wire (Boston Scientific)
via the pelvic collaterals
4. Catheter insertion
■ 0,014" Echelon microcatheter (Medtronic) into Endoleak
and following angiogram
5. Embolisation of Endoleak
■ Alcohol-colymer Onyx 34/34L (Medtronic)
6.After microcatheter removal final angiogram
via deep circumflex iliac artery to confirm complete
Endoleak embolisation
58
Wednesday, 11:16 – 11:38 Live from Heidelberg Technical Forum · Room 3
Case 53 – HEI 03: female 56 years (B-M)
TANDEM 40 TACE for HCC / Video of Isolated Chemosaturation
Operators: B. Radeleff, N. Kortes, M. Sumkauskaite, D. Gnutzmann,
N. Tessendorf, S. Schreiner, C. Ernst
Clinical data: Histological proven HCC seg. VIII
Ethyltoxic livercirrhosis (Child B, MELD 11)
Risk factors:
■
■
■
■
■
t ransfemoral approach over the right groin –
retrograde puncture
placement of a short 4-F sheath Radifocus
(Terumo) over an 0.035’’ 180 cm J-wire
Wednesday
Procedural
steps
Portal hypertension: hepatomegaly, ascites, fundal varices
Smoking and adipositas
Chronic pancreatitis, duodenitis and gastritis
lacement of an 4F 110 cm 4F Sidewinder Typ I
p
(Cordis) and pulling him into the celiac trunc
placement of an 2,8F Microcatheter Progreat
(Terumo) and superselective recanalization of
the hepatic artery
mbolisation of the HCC in the right liver lobe
e
using DEB-TACE: 40μm Tandem DEB-particles
(BSCJ) loaded with 150 mg of doxorubicin
■ Very important information:
During this session for HCC treatment,
we will show a 8 min. video case of an isolated
chemosaturation: a 38 years old male suffering
from bilateral hepatic metastases due to a
malignant uveal melanoma.
We will demonstrate on the video the
diagnostic angio with coiling of vessels and
then of the isolated chemosaturation itself.
59
Wednesday, 11:46 – 12:06 Live from Leipzig Technical Forum · Room 3
Case 54 – LEI 19: male, 57 years
Selective Internal Radiation Therapy (SIRT) for colorectal liver metastases
Operators: T-O. Petersen, M. Moche, T. Lincke
Clinical data: Liver metastases following rectal cancer (T3 N2b M1 G2 KRAS wild type)
Rectum resection 11 month ago, followed by nine cycles of FOLFIRI-Cetuximab
chemotherapy. After initial regressive disease now persisting metastases in the liver.
Hepatic function not impaired.
Risk factors:Art. hypertension
Slight focal cholestasis from tumor mass in liver segment VII
Procedural
steps
1. Right femoral approach
■ 4F 10 cm sheath (Terumo)
2. Catheterization of the hepatic artery
■ 4F-SIM2 100 cm diagnostic catheter (Cordis)
3.Placement of the microcatheter precisely in the same position 1 and 2
for the injection of the therapeutic agent
■ Microcatheter System 2.7F 130 cm (Terumo Progreat)
4.Selective application of the Yttrium-90 glass microspheres
with a dedicated injection system (TheraSphere, BTG)
Left side: MRI T1w with contrast showing one of the metastasis in liver segment VII
Right side: Evaluation procedure - Selective DSA of hepatic artery in late arterial phase with
multiple hypervascular nodules in the right liver lobe
Single photon emission computed tomography (SPECT) immediately after Tc-99m
injection in both positions with strong uptake
in the tumor. No extrahepatic uptake.
Both sides: Evaluation procedure – Superselective DSA with microcatheter position 1 (left
side) and position 2 (right side) for Tc-99m injection after coiling of the cystic artery, the right
gastric artery and a accessory pankreatic artery
60
Wednesday, 13:30 – 15:00 Live from Kingsport Technical Forum · Room 3
Aorto-Iliac Disease: Calcified AAA and right iliac aneurysm
Clinical data: Severe CAD and history of ischemic cardiomyopathy
CABG 1998 after MI
AICD implantation
Risk factors: DM, HTN, dyslipidemia, former smoker
1.Percutaneous EVAR with Ovation Prime system (Trivascular)
2. Consider vascular plugging of left internal iliac
Wednesday
Procedural
steps
AAA: 5.3 X 4.7 cm
RCIA 3.7 X 2.95 cm
61
Wednesday, 13:30 – 15:00 Live from Kingsport Technical Forum · Room 3
Complex aorto-iliac occlusion
Clinical data: Severe CAD, s/p CABG 1990, recent NSTEMI w/ 100 SVG→ OM
Htn, NIDDM, CRI w/ Cr 1.6, dyslipidemia
Severe carotid disease w/ recent TIA's, R PSV 409 cm/sec,
LICA PSV 390 cm/sec, RICA CAS. L Renal stent, severe Htn nephrosclerosis
Risk factors:HTN, dyslipidemia, multi-vessel-disease
Severe claudication R>>L
ABI:Right 0.42, left 0.78
Procedural
steps
1.Panel discussion regarding access
for imaging and stenting R external and common iliacs
2. Panel discussion regarding CTO crossing and stent choices/techniques
3. PTA external iliac
n Armada Balloon (Abbott)
n possibly DCB In.Pact Admiral 7/120 mm (Medtronic)
Stent-choices:
n Absolute Pro 8-9/100 mm (Abbott)
n Omnilink 9/29 mm (Abbott)
62
Wednesday, 16:30 – 18:00 Live from Leipzig
Case 57 – LEI 20: male, 68 years (K-A)
Infrarenal aortic stenosis and bilateral iliac occlusions, Leriche-Syndrome
Operators: A. Schmidt, H. Staab, D. Branzan
Clinical data: Claudication intermittens, walking capacity 50 meters
Weakness and pain buttock, thigh and calf bilateral
ABI bilateral 0.67
CAD, PTCA 2012 and 2013, cardiomyopathy, EF 45%
Adipositas
Gastric surgery due to perforation 2001
Wednesday
Risk factors:Art. hypertension, hyperlipidemia
Procedural
steps
1. Transbrachial approach
■ 6F 90 cm Check-Flo performer sheath (COOK)
■ 5F 125 cm diagnostic Judkins Right catheter (CORDIS/CARDINAL HEALTH)
■ SupraCore 300 cm 0.035" guidewire (ABBOTT)
2. Passage of the occlusions
■ Stiff angled 0,035" guidewire, 260 cm (TERUMO)
■ Together with 5F-125 cm Judkins Right Catheter
3.Bilateral groin access
■ 7F 10 cm Radiofocus sheath (TERUMO)
■ Snaring of the antegrade guidewire form above into the groin-sheath or
■ Into 6F-Judkins-Right guiding catheter (CORDIS), inserted form below
4.PTA via the groin access bilateral
■ SupraCore 300 cm 0,035" guidewire (ABBOTT)
■ Admiral balloon 6.0/120 mm bilateral (MEDTRONIC)
5.Stenting
■ Aorta: Sinus XL Aortic Stent (OPTIMED)
■ Common iliac arteries: 8.0/59 mm LifeStream covered Stentgrafts
in Kissing technique (C.R.BARD)
■ External iliac artery bilateral: 8.0/120 mm Absolute Pro Stent bilateral (ABBOTT)
63
Wednesday, 08:00–08:20 Live from Leipzig Global Expert Exchange Forum · Room 5
Case 58 – LEI 21: male, 75 years (L-W)
Calcified distal SFA occlusion right
Clinical data: Restpain right foot, Rutherford class 4
ABI right > 1.3
Unsuccessful recanalization attempt right SFA 11/2015
PTA/stenting left SFA 11/2015 elsewhere
Risk factors:
Procedural
steps:
Art. hypertension, hyperlipidemia, current smoker
Chronic renal insufficiency with GFR 73 ml/min
1. Right groin antegrade access
■ 7F-10 cm Radiofocus II sheath (TERUMO)
2. Guidewire-passage
■ 0.018" CXC support-catheter (COOK)
■ 0.014" CTO-Approach 25 gramm guidewire, 300 cm (COOK)
In case of failure to pass the CTO from antegrade:
Retrograde access via the distal SFA
■ 9 cm 21 gauge puncture needle (COOK)
■ 0.018" V-18 control guidewire (BOSTON SCIENTIFIC)
■ 0.018" CXC support-catheter (COOK)
3. Predilatation
■ Advance Enforcer 35 Focal-Force PTA-balloon catheter 6.0/40 mm (COOK)
4. PTA with Drug-Coated Balloons
■ LegFlow 6.0/120mm (CARDIONOVUM)
64
Wednesday, 09:09 – 09:29 Live from Dendermonde Global Expert Exchange Forum · Room 5
Case 59 – DEN 05: female, 83 years (S-L)
Left calcified popliteal CTO
Operators: K. Deloose, J. Callaert
Clinical data: History: 2008 CAS right, 2010 PTAS popliteal right, 2010 CEA left, 2011
PTCA + CABG, 2015 PTRA bilateral
Present State: non-healing ulcer left leg since 1 month
Risk factors:
Insuline dependent diabetes mellitus
Arterial hypertension, hypercholesterolemia
1.Right CFA access - crossover
■ 0.035", 260 cm glidewire (Terumo)
■ RIM catheter (Cook)
Wednesday
Procedural
steps
2. Recanalization
■ CXI catheter 0.018", 150 cm (Cook)
3. Predilatation
■ Angiosculpt 5 or 6 mm (Spectranetics)
4. Stenting
■ Supera VMI (5 or 6 mm) (Abbott Vascular)
5. Postdilatation
6. Assistance GE Healthcare
■ Vessel assist - "Center Line Tracking"
7. Plan B
■ Distal puncture + retrograde/bidirectional recanalization
65
Wednesday, 10:04 – 10:24 Live from Leipzig Global Expert Exchange Forum · Room 5
Case 60 – LEI 22: male, 76 years (D-J)
Critical limb ischemia with BTK-occlusions right
Clinical data: Diabetic foot with deep Dig I ulceration right
PAOD with Rutherford class 5
PTA left SFA and BTK due to CLI 1/2016
Risk factors:
Procedural
steps
CAD, PTCA 2011
Chronic renal insufficiency GFR 67ml/min
Angiography right during PTA left leg: CTO of the tibioperoneal trunk
1. Right antegrade access
■ 0.014" CTO-approach guidewire, 300 cm (COOK)
■ 0.018" CXC support-catheter, 90 cm (COOK)
3. PTA and stenting
■ 3.0/20 mm MiniTrek RX balloon (ABBOTT)
■ Stentys selfexpanding PTX-stent (STENTYS)
66
Wednesday, 15:30 – 16:00 Live from Heidelberg Global Expert Exchange Forum · Room 5
Case 61 – HEI 04: male 62 years (J-F)
Superselective Embolisation of an AVM using ONYX
Operators: B. Radeleff, N. Kortes, M. Sumkauskaite, D. Gnutzmann,
N. Tessendorf, S. Schreiner, C. Ernst
Clinical data: Peripheral highflow arteriovenous malformation (AVM) re. forearm (ED 2012)
Low symptom level
Risk factors:
MI 2002, 2009, 2012
PTCA/stent 2012
Ex-smoker, arterial hypertension
Attached is one image showing the AVM
■
■
■
Intervention in general anaesthesia
ransfemoral approach over the right groin – antegrade puncture
t
placement of a short 4-F sheath Radifocus (Terumo)
over an 0.035’’ 180 cm J-wire
■
lacement of an 4F 65 cm 4F Glidecath-catheter Terumo and placing him BTK
p
placement of an 2,0-2,8F Microcatheter Progreat (Terumo)
and superselective recanalization of the central AVM-feeder
■
embolisation of the peripheral AVM using 18-ONYX (MEDTRONIC)
■
Wednesday
Procedural
steps
67
68
L e i p z i g
C o u r s e
2 0 1 6
Thursday
Thursday,
January 28, 2016
69
Thursday, 08:00 – 08:25 Live from Leipzig Main Arena 1 · Room 1
Case 62 – LEI 22: male, 72 years, (H-S)
Critical limb ischemia, BTK-occlusions right, failed recanalization attempt
Clinical data: Critical limb ischemia with restpain right forefoot
Rutherdord class 4, ABI right 0.35
Failed recanalization attempt of the anterior tibial and peronal artery right
elsewhere 1/2016
CAD, CABG 2012
Minor stroke 2012, after CABG without residual symptoms
Risk factors: Art. hypertension, former smoker, hyperlipidemia
Angiography: Total occlusion of the mid anterior tibial artery and TPT
Procedural
steps
1.Right antegrade access
■ 6F-55 cm sheath (COOK) (in case of kissing balloon/stent treatment BTK)
2.After failed antegrade recanalization attempt:
retrograde approach via the dorsalis pedis and/or peroneal artery
■ 21 Gauge 7 cm needle (COOK)
■ 0.018" Connect guidewire, 300 cm (ABBOTT)
■ 0.018" CXC support-catheter, 90 cm (COOK)
3.PTA and stenting (after snaring of the guidewire from antegrade)
■ Armada 14 2.5/80 mm balloon (ABBOTT)
■ Stentys BTK PTX-eluting selfexpanding stent (STENTYS)
70
Thursday, 08:46 – 09:09 Live from Abano Terme Main Arena 1 · Room 1
Case 63 – ABT 01: female, 53 years
Popliteal/AT/PT and foot recanalization
Operators: M. Manzi, L. M. Palena, C. Brigato
Clinical data: AF
Acute and subacute popliteal occlusion recanalized twice (2013-2015)
Right foot small ulceration 1st toe and heel
Hypertension, dyslipidemia
Right popliteal occlusion extended to AT and PT
Pedal and lateral plantar occlusion
Thursday
Risk factors: Procedural
steps
1.US guided antegrade CFA puncture
■ Terumo 6F short sheath
2. 4F BER 2 + V18 CW popliteal and AT/PT antegrade intraluminal approach
Retrograde distal AT puncture if failure
3.Popliteal DEB angioplasty and tibial POBA
4.US guided closure device deployment
■ 6F Angio-Seal
71
Thursday, 09:46 – 10:15 Live from Bad Krozingen Main Arena 1 · Room 1
Case 64 – BK 01: female, 59 years (R-S)
Plaque modulation (Angiosculpt) and DCB femoro-popliteal lesions
Operators: E. Noory, P. Flügel
Clinical data: Claudication Rutherford 3 (<200 m) right calf
Risk factors: Hypertension, diabetes mellitus, hyperlipidemia
ABI at rest: Right: 0.6, left: 0.9
Duplex: Multiple high grade stenoses distal SFA and popliteal artery right leg
Procedural
steps
1. 6F cross-over sheath from the left groin
2. Crossing the lesions
■ 0.014" or 0.018" Advantage GW (Terumo)
3.Plaque modulation
■ Angiosculpt balloon catheter (Spectranetics)
4.Predilatation
■ 5 mm Angiosculpt catheter (Spectranetics)
5. Long-term (3 minutes) postdilatation
■ 5 or 6 mm Stellarex DCB (Spectranetics)
6.No stents if possible
72
Case 65 – LEI 23: female, 60 years (J-S)
In-Stent Reocclusion left
Clinical data: Severe claudication left calf, walking capacity 150 meters
Rutherford class 3
Stenting of the SFA left 12/2013
Recurrent, progressive symptoms since 4 months
Risk factors: Art, hypertension, current smoker
Diabetes mellitus typ 2
CAD, PTCA 12/2014
Duplex: Total occlusion of the the stents left SFA, Tosaca III
1.Right groin and cross-over approach
■ Judkins Right 5F diagnostic catheter (CORDIS/CARDINAL HEALTH)
■ 0,035" SupraCore Guidwire 30cm (ABBOTT)
2.Guidewire-passage of the in-stent reocclusion
■ 0.035" Halfstiff Terumo 260 cm (TERUMO)
■ 0.035" QuickCross support-catheter, 135 cm (SPECTRANETICS)
■ Exchange to a 0.014" Floppy ES guidewire 300 cm (ABBOTT)
3. Laser-atherectomy
■ 7F Tandem Booster-Laser (SPECTRANETICS)
4.PTA with DCBs
■ Stellarex 6.0/120 mm DCBs (SPECTRANETICS)
Thursday
Procedural
steps
73
Thursday, 11:25–11:45 Live from Münster Main Arena 1 · Room 1
Case 66 – MUN 05: male, 64 years (G-H
Optical coherence guided atherectomy
of grade 2 instent restenosis (ISR) left SFA
Operators: A. Schwindt, S. Stahlhoff
Clinical data: Recanalistion and stent-PTA left SFA 7/15 (5x150 Everflex, Medtronic),
Up to date recurrent claudication Rutherford 2 with walking distance of 300m,
in DUS diffuse ISR left SFA with peak systolic velocity of 300cm/sec.
ABI right leg 1,2; left leg 0,7
Risk factors: Arterial hypertension
ABI: Right 1.2, left 0.7
Procedural
steps
1.Right femoral access
■ 8F 45 cm destination sheath (Terumo) up-and-over into left SFA
2. Cannulation of ISR left SFA
■ 0,035" Advantage wire (Terumo) and placement of
■ 6 mm Spiderfilter (Medronic) throught
■ 0,035" Quickcross recanalisation catheter in popliteal artery
3.Optical coherence guided atherectomy of ISR
■ 8F Pantheris directional atherectomy catheter (Avinger)
4.After debulking PTA with drug-eluting balloon
■ In.Pact Admiral 5 x 150 (Medtronic)
74
Case 67 – MUN 06: female 58 years (M-H. V.)
Optical coherence guided directional atherectomy
of 25 cm diffuse SFA stenosis with 8 cm CTO
Operators: A. Schwindt, S. Stahlhoff
Clinical data: PAOD left leg Rutherford III with 150m walking distance.
Pantheris atherectomy right SFA 8/2015
DUS and DSA confirm 25 cm stenosis and CTO of left SFA
Risk factors: Hypertension, hyperlipidemia, insulin dependent diabetes mellitus type II
Thursday
ABI: Right leg 1.2; left leg 0.56
Procedural
steps
1.Right femoral access
■ 8F 45 cm destination sheath (Terumo) up-and-over into left SFA
2.True lumen recanalisation left SFA
■ 6F Ocelot 200 OCT-guided recanalisation catheter (Avinger)
■ 0,014 Choice PT II wire (Boston Scientific)
Placement of
■ 6 mm Spiderfilter (Medronic) throught
■ 0,035" Quickcross recanalisation catheter in popliteal artery
3.Optical coherence guided atherectomy of left SFA
■ 8F Pantheris directional atherectomy catheter (Avinger)
4.After debulking PTA with drug-eluting balloons
■ 2 x In.Pact Admiral 5 x 150 (Medtronic)
75
Case 68 – LEI 24: male 76 years (H-H)
Retrograde approach using a 2.9F pedal sheath in CLI
Clinical data: Critical limb ischemia with forefoot gangrene left
Rutherford class 5, ABI > 1.3
Failed recanalization attempt 01/2016 of an occluded anterior tibal artery
Risk factors: Diabetes mellitus type 2, art. hypertension
Angiography: During recanalization attempt:
Left: SFA, Apop and peroneal artery patent, posterior and anterior tibial artery occluded
Guidewire-perforation in the mid segment of the anterio tibial artery
Procedural
steps
1.Antegrade left access
2.Retrograde approach via the dorsalis pedis artery
■ Pedal puncture kit (COOK)
■ 21 Gauge 4 cm needle (COOK)
■ 2.9F ID pedal sheath (COOK)
3.Retrograde passage of the ATA-occlusion left
■ 0.018" straight CXI support-catheter, 90 cm (COOK)
■ 0.014" Hydro-ST guidewire, 300 cm (COOK)
■ 0.014" CTO-Approach 25 gramm 300 cm guidewire (COOK)
4.PTA from retrograde
■ Advance Micro balloon 2.5/120 mm (COOK)
76
Thursday, 13:30 – 15:00 Live from Abano Terme Main Arena 1 · Room 1
Case 69 – ABT 02: female 83 years (S-S)
Multilevel disease; AT and pedal recanalization
Clinical data: Type 2 DM
Right foot 2nd toe gangrene
TcPO2 = 11 mmHg
Risk factors: Ischemic heart disease, hypertension
1.US guided antegrade CFA puncture and 6F Terumo short sheath deployment
4F BER 2 + V18 CW
2.SFA/popliteal POBA and stenting discussion
3.Antegrade subintimal AT recanalization
0.014 bi-directional wiring if failure
4. DEB discussion
5.US guided closure device deployment (Angio-Seal)
Thursday
Procedural
steps
77
Case 70 – BK 02: male, 64 years (P-W)
Chronic embolic occlusion of distal SFA, popliteal and BTK arteries
Operators: T. Zeller, E. Noory
Clinical data: Claudication Rutherford 3 (50m) left calf since 1 year
Sudden onset of symptoms
Embolic nature, source: intra cardiac thrombus as a result of an anterior wall infarction
Oral anticoagulation
Risk factors: CVRF: Nicotine, family history
ABI: right 1.1, left 0.6
Duplex: Thrombotic occlusion of distal left SFA
Procedural
steps
1. 7F antegrade sheath left CFA
2.Intraluminal lesion passage
■ 4F vertebral diagnostic catheter (Cordis) 0.018’’ or
■ 0.014” Advantage GW (Terumo)
3. Mechanical thrombectomy
■ Rotarex 6F (Straub Medical)
or directional atherectomy
■ Silverhawk LX-M (Medtronic)
4. DCB angioplasty
■ IN.PACT Pacific (Medtronic)
5. Local lysis if indicated
6.No stents!
78
Case 71 – LEI 25: male, 76 years (W-K)
Popliteal occusion right, previous unsuccessful recanalization attempt
Operators: A. Schmidt, S. Bräunlich
Clinical data: Restpain and severe claudication right foot and calf
11/2015 unsuccessful recanalization attempt elsewhere with
inability to redirect the guidewire into the true lumen distally
ABI: Right 0.47
Risk factors: Art. hypertension, former smoker, hyperlipidaemia
■ 6F-55 cm Check-Flo Performer sheath (COOK)
2.Second attempt to pass the occlusion from antegrade
■ 0.018" Connect 250 T guidewire, 300 cm (ABBOTT)
■ Pacific balloon 3.0/80 mm (MEDTRONIC)
3.In case of failure retrograde approach via the peroneal artery
■ 21 gauge 7 cm puncture needle (COOK)
■ 0.018" V-18 Control guidewire, 300 cm (BOSTON SCIENTIFIC)
■ 0.018" TrailBlazer support-catheter, 90 cm (MEDTRONIC/COVIDIEN)
■ Snaring of the guidewire from antegrade after passage of the CTO
4.Vessel preparation and PTA from antegrade
■ FLEX Plaque-Modification catheter (VENTUREMEDGROUP)
■ Lutonix DCB (C.R.BARD)
5.Stenting on indication
■ Multi-LOC Multiple-Stent-Delivery-System (B.BRAUN) or
■ Supera Interwoven Nitinol-Stent (ABBOTT)
Thursday
Procedural
steps
79
Case 72 – BK 03: female, 64 years (M-F)
Stent angioplasty of renal artery stenosis right side
Clinical data: Since more than 15 years known history of hypertension
Sudden onset of symptoms of recurrent hypertensive crisis in September 2015
Coronary 2-vessel disease
PCI / DES LAD and Rcx 2012
Normal LV function
Negative stress echo up to 125 W 10/2015
Present state: OBP: 190/80 mmHg
ABPM: 164/81 mmHg
Creatinine: 0.8 mg/dl
eGFR: 80 ml/min
Duplex: Kidney length R/L: 119 mm/118 mm
Acceleration time: > 70 ms/< 70 ms
Intrarenal RI R/L: 0,74/0,81
RA PSV- ratio R/L: 4.5/1.8
Procedural
steps
1. 6F retrograde sheath right groin (11 cm)
2. 6F IMA guiding catheter via standard 0.038" GW
3.Non-selective angiography (DSA)
4.Selective angiography
5. Lesion crossing with a 0.014" GW (Galeo ES, BIOTRONIK)
6. Direct stenting if feasible, predilatation on indication
■ Hippocampus (Medtronic) or Dynamic renal (Biotronik)
7. Closure device
■ Femoseal (St. Jude)
80
Thursday, 15:59 – 16:16 Live from Teaneck Main Arena 1 · Room 1
Case 73 – TEA 01: male, 73 years (C-C)
Trans-radial hemodialysis access
Operators: J. Rundback, K. Herman, A. Patel
Clinical data: 73 yo male with radio-cephalic fistual at the wrist for follow up venography.
Poor flows on HD.
Risk factors: ESRD on HD, multiple fistula interventions in the past
1.US guided right radial artery access
and palcement of a 4F or 6F slender sheath (Terumo)
2. 018" Advance 18 lp PTA balloon (Cook)
Thursday
Procedural
steps
3.Access forearm collateral vein
■ 5F Rim catheter, followed by
■ 2.8 Fr Progreat for co-axial technique and coil embolization using
■ 018" Interlock (Boston Scientific)
81
Thursday, 16:30 – 18:00 Live from Bad Krozingen
Case 74 – BK 04: male, 79 years (B-H)
Chronic occlusion of left SFA, popliteal and BTK arteries
Clinical data: Claudication Rutherford 3 (<50m) both legs for years
with progressive deterioration during a the last couple of months
ABI: right 0.3, left 0.4
Risk factors: Hypertension, former smoker, hyperlipidemia
Duplex: Chronic bilateral SFA occlusion plus occlusion of left popliteal artery middle segment
Procedural
steps
1. 7F cross-over Destination- sheath from the right groin (TERUMO)
2.In the unlikely case of intraluminal lesion passage: Mechanical thrombectomy
(Rotarex; STRAUB MEDICAL)
3.If subintimal: predilatation with plain balloon, if result insufficient
directional atherectomy & DCB angioplasty (TurboHawk and In.Pact DCB; MEDTRONIC)
4.Stent only on indication (provisional stenting) (Supera Interwoven Nitinol-Stent; ABBOTT)
5.In case of failed antegrade recanalization attempt retrograde access via left ATA
82
Thursday, 16:30 – 18:00 Live from Teaneck
Case 75 – TEA 02
Thursday
For case information please download the LINC 2016 App
or visit the LINC 2016 website.
83
Thursday, 08:35–08:55 Live from Münster Case 76 – MUN 07: male, 62 years (B-F)
Thoracic stentgraft implantation
Operators: P. Cao, B. Gehringhoff, M. Austermann, M. Bosiers
Clinical data: 69 mm TAA
Risk factors: PAD, CAD, hypertension
Procedural
steps
1.Percutanous approach right groin
■ Prostar XL (Abbott)
■ 14F sheath (COOK)
2.Placement of a 5F sheath and a pigtail catheter
through the left groin for imaging
3.If necessary ilical conduit Bypass dacron 10 mm
4.Implantation of the thoracic Bolton RELAY PLUS endograft
(BOLTON MEDICAL)
5. Closure of the groins
84
Thursday, 09:40 – 10:05 and 10:25 – 10:50 Live from Leipzig Main Arena 2 · Room 2
Case 77 – LEI 26: male, 74 years, (W-F)
EVAR with a NELLIX endovascular aneurysm sealing system
Operators: A. Schmidt, D. Branzan, A. Winterbottom, M. Moche
Clinical data: Progressive abdominal aortic aneurysm, max. diameter 55mm
CAD, PTCA 2012
Art. hypertension
Pulmonary embolism, mild dyspnoe 11/2015
Duplex: Duplex-sonographic surveillance for a few years
Progression from < 5.0 cm to 5.5 cm within a year
Procedural
steps
Thursday
Max. diameter 52mm
No thrombus formation
1.Percutaneous approach
with local anaesthesia both groins
■ Preloading of 2 Proglide-Systems
per groin (ABBOTT)
■ 0.035" LunderQuist 200 cm guidwires
via both groins (COOK)
■ Calibration angiography
to estimate the graft-length
2. Bilateral insertion of the Nellix-systems (ENDOLOGIX)
■ Implantation of the 10 mm-diameter stentgrafts with integrated balloons
■ Pre-filling of Nellix Endobags with pressure-monitoring (ENDOLOGIX)
■ After aspiration of the pre-fill injection of the Polymer-filling
■ Postdilatation with integrated 10 mm balloons
3.Groin-closure after final angiography
85
Case 78 – LEI 27: male, 60 years (NH-B)
EVAR with Gore Side-Branch Device
Operators: A. Schmidt, D. Branzan, H. Staab, F. Verzini
Clinical data: Incidental finding of a 70mm abdominal aortic aneurysm
and 60mm aneurysm of the left common iliac artery
Non-Hodgkin Lymphoma
Risk factors: Art. hypertension, adipositas (BMI 34,4 kg/m2)
Procedural
steps
1.General anesthesia and percutaneous approach
■ Preloading of 2 Proglide-Systems per groin (ABBOTT)
2.■
■
■
■
Lunderquist Extra Stiff Wire guide 180 cm (COOK) from left
12F-45 cm sheath via right groin (COOK)
Snaring of a pull-through guidewire from left to right groin
0.035" stiff angled Radiofocus glidewire, 260 cm (TERUMO)
3. ■ Implantation of a Gore Excluder Iliac Branch Endoprosthesis (IBE)
from left (W.L.GORE)
■ Implantation of a Viabahn via the 12F-sheath into the hypogastric artery left
4.
■Implantation
■
of the main body via right groin:
3 Gore Excluder (W.L.GORE) and
C
Implantation of a brindging stent between C3 Excluder and Gore IBE
5.Postdilatation of the graft
86
Case 79 – MUN 08: male, 71 years (H-M)
EVAR with chimney both renal arteries
Operators: M. Austermann, B. Gehringhoff, M. Bosiers
Clinical data: Juxtarenal growing aneurysm 62 mm
PAD with severe calcified and stenosed iliac arteries
Common ostium of the CT and SMA
Risk factors: Art. hypertension
CAD
1.Percutanous approach both groins
■ Placement of 14F sheath (COOK)
Thursday
Procedural
steps
2.Cut down left axillary artery and double puncture
3.Placement of two 7 F Shuttle sheaths from above.
Cannulation of both renal arteries with a 7 F shuttle sheath (COOK)
4.Placement of Endurant bifurcated endograft (Medtronic)
just below the SMA
5.Placement of the chimney stent-grafts (Advanta-Maquet)
in both renal arteries
6.Closure of the groin
87
Case 80 – MUN 09: female, 82 years (W-E)
Sealing of a type 1a endoleak after EVAR
with a proximal extension and fixation with endoanchors
Operators: M. Austermann, M. Bosiers
Clinical data: Growing abdominal aortic aneurysm after EVAR
due to a type 1a endoleak beside a migrated endograft
Risk factors: Art. hypertension, cardiac insufficiency, PAD, CAD
Procedural
steps
1.Percutanous approach right groins Prostar XL (Abbott).
14 F sheaths (COOK)
2.Puncture of the other groin and placement of a pigtail-catheter for imaging
3.Proximal extension of the existent endograft with a Endurant tube graft
4.Fixation at the short infrarenal neck with Aptus Heli-FX Endoanchors (MEDTRONIC)
5.Closure of the groin
88
Case 81 – LEI 28: male
Fenestrated EVAR for a juxtarenal aortic aneurysm
Operators: A. Schmidt, D. Branzan, H. Staab
Clinical data: Progressive juxtarenal aneurysm
Incidental finding during an episode of abdominal pain
CAD, PTCA 20120
Risk factors: Art. hypertension, former smoker
1.General anaesthesia
Percutaneous approach via both groins and left axillary artery
■ Preloading of 2 Proglide-systems per groin and left axillary artery (ABBOTT)
■ 12F-45 cm Sheath via left brachial artery (COOK)
■ 0.035" Lunderquist 300 cm (COOK) pullthrough left groin to axillary artery using a
■ Snare-kit 10 mm (COVIDIEN/MEDTRONIC)
Thursday
Procedural
steps
2.Precannulation of the visceral arteries before stentgraft implantation
■ 16F-30 cm sheath via right groin (COOK)
■ SOS Omni-Selective 5F-catheter (ANGIODYNAMICS)
■ Stabilization with guidewires: Galeo Pro (BIOTRONIK)
3.Stentgraft implantation
■ Implantation of the 4-vessl branched CMD-stentgraft (JOTEC) via left groin
■ Removal of the stentgraft delivery system and partiall closure left groin
4. Cannulation of the visveral arteries
■ Puncture of the valve of the 12F-45 cm sheath axillary artery and
insertion of a 7F-55 cm sheath (COOK)
■ Judkins Right Diagnostic Catheter (CORDIS)
■ 0.018" V-18-Control Guidewire 300 cm (BOSTON SCIENTIFIC)
5.Implantation of covered stents to the visceral arteries
■ E-ventus BX stentgrafts (JOTEC)
89
Thursday, 08:00 – 09:00 Live Bad Krozingen Technical Forum · Room 3
Case 82 – BK 05: male, 61 years (G-H)
Recanalisation of EIA/CFA and SFA left leg
Clinical data: Calf & leg claudication left leg, calf claudication right leg about 200 m
with progressive deterioration since a couple of weeks
Interventional treatment of the left CFA 2007 in an external hospital
Coronary 2-vessel disease
PCI / DES 2009, 3/2010, 6/2010
AMI (posterior wall) 2009
Moderate reduction of LV function
ABI at rest: 0.4 / 0.3, ABI after exercise: 0.2 / 0.1
Oscillometry: reduced amplitudes right calf & ankle
Reduced amplitudes left tigh, calf & ankle
Duplex left leg: Occlusion of EIA & CFA (vessel diameter 11 mm!)
Moderate to high grade stenosis of DFA
Proximal occlusion of SFA (reperfusion distally)
Crea/eGFR: 1.3 mg/dl / 76.3 ml/min
Procedural
steps
1. 8F cross-over sheath right groin
■ Balkin Up&Over (COOK)
2.Intraluminal passage of EIA/CFA occlusion
■ 0.018" % 0.035" Advantage GW (TERUMO)
3.8F Rotarex (STRAUB MEDICAL) if soft tissue,
■ Turbohawk atherectomy (MEDTRONIC) if solid
4. DEB angioplasty
■ Lutonix (C.R.BARD) if vessel size >7 mm In.Pact (MEDTRONIC)
5. Lesion crossing of SFA with a 0.018" GW
6.Predilatation (conventional balloon)
7. DEB and spot stent on indication
■ BioMimics (VERYAN MEDICAL)
8. Closure device
■ 8F Angioseal (ST JUDE)
90
Thursday, 10:00 – 11:30 Live from Abano Terme Technical Forum · Room 3
Case 83 – ABT 03: female, 81 years (P-A)
Antegrade AT/PT and pedal/arch recanalization
Clinical data: Type 2 DM
Hypertension
Left foot 2nd and 3rd toe gangrene
Creatinine 1.6 (good candidate for CO2 angiography)
1.US guided antegrade puncture and 6F, 11 cm Terumo sheath
2. 4F BER II + V18 CW intra/subintimal AT/PT approach
Bidirectional wiring if failure
0.014 Pilot and arch recanalization
3. 2/2.5 mm long POBA (2 mins)
DEB discussion
4.Perfusion angio
5.US guided closure device (6F Angio-Seal) deployment
Thursday
Procedural
steps
91
Thursday, 10:00 – 11:30 Live from Bad Krozingen Technical Forum · Room 3
Case 84 – BK 06: male, 65 years (R-L)
Atherectomy & DEB of common femoral artery
Operators: T. Zeller
Clinical data: Chronic bilateral POAD
Recurrence of calf claudication right leg since a couple of weeks, Rutherford 3
Right leg: PTA SFA & popliteal artery 08/2006
Stent EIA, PTA CFA, DES SFA, PTA ATA 07/2014
Left leg: Stent CIA, SFA-recanalisation (DES&DEB) 04/2013
Stent EIA DEB&stent DFA, Rotarex thrombectomy & DEB SFA
Present state: ABI at rest: 0.4 / 0.9
Oscillometry: reduced amplitudes right tigh (mild), calf & ankle (moderate)
normal amplitudes left tigh, calf & ankle
Duplex right leg: Approx. 70 CFA stenosis
Occlusion of SFA
Very diffuse calcification)
Angio: only partially available (06/2015)
Procedural
steps
1.7F cross-over sheath left groin
■ Ansel (COOK)
2.Turbohawk atherectomy & DEB right CFA & SFA origin under filter protection
■ LX-C TurboHawk and Spider EPD (MEDTRONIC)
3. Lesion crossing of SFA with a 0.018" GW
■ Advantage Guidewire (TERUMO)
4.Rotarex thrombectomy if soft occlusive tissue (STRAUB MEDICAL),
otherwise Turbohawk atherectomy
5. DEB and spot stent on indication
■ In.Pact DCB (MEDTRONIC) and BioMimics (VERYAN MEDICAL) or
Supera-Stent (ABBOTT)
6. Manual sheath removal
92
Thursday, 12:10 – 12:25 Live from Leipzig Technical Forum · Room 3
Case 85 – LEI 29: male, 72 years (S-D)
CGuard Carotid Embolic Prevention System
for treatment of a carotid artery stenosis
Operators: A. Schmidt, S. Bräunlich
Clinical data: Highgrade internal carotid artery stenosis left
Left-hemispheric minor stroke 2014 without residual symptoms
Highgrade vertebral artery stenosis right, left vertebral hypoplastic
NSTEMI 11/2015 with PTCA left LAD and main stem
Hypertensive cardiomyopathy, NYHA II-III
Chronic renal insufficiency, GFR 49ml / min
Risk factors: Arterial hypertension, former smoker
Angiography: During coronary angiography: 90% ICA-stenosis left
Duplex: PSV 4.m/sec left ICA
1.Right groin access
■ 6F-90 cm Tuohy-Borst sheath (COOK)
2.Protection system
■ Wirion protection device (ALLIUM-MEDICAL)
3.Predilatation, stenting and postdilatation
■ 4.0/20mm MiniTrek RX-balloon (ABBOTT)
■ 7.0 or 8/20mm CGuard carotid embolic prevention system
(InspireMD/PENUMBRA)
■ 5.0/20 mm Sterling RX-balloon for postdilatation
(BOSTON SCIENTIFIC)
Thursday
Procedural
steps
93
Thursday, 13:37 – 14:08 Live from Teaneck Technical Forum · Room 3
Case 86 – TEA 03: male, 89 years (R-Q)
Decreased access flow rates
Operators: J. Rundback, K. Herman, A. Patel
Clinical data: 89 yo male with ESRD on HD with dysfunctional LUE radio-cephalic fistula
at the wrist, decreased access flow rates greater than 25% drop
from 900 ml/min to 600 ml/min. Multiple prior interventions in the past
(beginning in 2009).
Most recent intervention 3 months prior.
Risk factors: DM, CAD, DM
Procedural
steps
1.US guided left radial artery access
■ 4F or 6F slender sheath (Terumo)
2.Boston Scientific 018" V18 wire
3. Boston Scientific Sterling 018" PTA catheter
94
L e i p z i g
C o u r s e
2 0 1 6
Friday
Friday,
January 29, 2016
95
Friday, 09:00 – 09:40 and 10:15 - 10:45 Live from Münster Case 87 – MUN 10: female, 61 years (W-H)
LP-branched endovascular aortic repair
Clinical data: Thoracoabdominal aortic aneurysm
Narrow iliac arteries
Risk factors: Art. hypertension
Panarteritis nodosa
Procedural
steps
1. Percutanous approach both groins
■ 14F (COOK) both groins
2. Left axillary access 5F sheath via cut down
3.Placement of a LP-CMD - Zenith-endograft (COOK)
with four branches and closure of the groins to avoid SCI
4.Cannulation of celiac trunk, SMA and renal arteries
through the branches and implantation of the bridging stentgafts
5. Final angiography
6.Closure left axillary access
96
Friday, 11:20 - 12:00 Live from Münster Main Arena 1 · Room 1
Case 88 – MUN 11: male, 70 years (Q-M)
4-fenestrated endovascular repair of a juxtarenal aortic aneurysm
Clinical data: Huge juxtarenal aortic aneurysm 75 mm
Risk factors: Art. hypertension, CAD, atrial fibrillation, COLD, hostile abdomen
1. Percutanous approach both groins (Prostar XL, Abbott) 14 F (COOK) both groins.
2.14 F Flexor sheath (COOK) both groins.
Changing of the left 14 F sheath for a 22F sheath
3.Placement of three 5 F sheaths into the 22F sheath and pre-cannulation
of the renal arteries and SMA by using fusion technology.
4. Placement of the 4-fenestrated Zenith-endograft (tube) (COOK) via the right groin.
5.Cannulation of the renal arteries through the fenestrations.
Cannulation of the SMA through the fenestration from above
6.Advancement of 7 and 8 F sheath into the target vessels.
Complete release of the endograft and stenting of the fenestrations with covered
stents (Advanta V12-Maquet) and flairing. Cannulation of the CT and stenting.
7. Placement of the distal bifurcated graft
8.Closure of the accesses
Friday
Procedural
steps
97
Friday, 09:00 – 09:45 Live from Leipzig Technical Forum · Room 3
Case 89 – LEI 30: male, 54 years (G-M)
Complex SFA-occlusion right
Clinical data: Severe claudication bilateral, right > left, restpain right foot, Rutherford 4
walking capacity 60 meters
ABI right 0.55
PTA of iliac stenosis bilateral 11/2015
Persistent symptoms
Risk factors: Art. hypertension, current smoker
Procedural
steps
■ 7F 55 cm Check-Flow-Performer sheath (COOK)
2. Atherectomy of the profunda femoris stenosis right
3. Passage of the SFA-occlusion and filter placement
■ 0.018" Connect guidewire 300 cm (ABBOTT)
■ 0,018" QuickCross Support-Catheter, 135 cm (SPECTRANETICS)
■ Wirion-Protection system (ALLIUM-MEDICAL)
4.Atherectomy of the superficial femoral artery
5. PTA with drug-coated balloons
■ Ranger DCB 5.0/120 mm
(BOSTON SCIENTIFIC)
98
Case 90 – LEI 31: male, 62 years (R-K)
High grade stenosis brachiocphalic trunk
Clinical data: Minor stroke right hemispheric 2011, no residual symptoms
Intermittent vertigo
Intermittent atrial fibrillation
CAD, MI 2012
COPD
Risk factors: Art. hypertension, former smoker, diabetes mellitus type 2
Duplex: Retrograde flow right vertebral artery
MR-angiography: High grade stenosis origin of the brachiocephalic trunk
1. Right groin access
■ 5F-Judkins Right diagnostic catheter (CORDIS/CARDINAL HEALTH)
■ 0.035" SupraCore guidewire 300 cm (ABBOTT)
■ 7F 90 cm Check-Flo Performer sheath (COOK)
■ Guidewire-position into the subclavian artery
2. Potentially cerebral protection with a filter via a right brachial access
■ 6F IMA guiding catheter (MEDTRONIC)
■ Filterwire EZ (BOSTON SCIENTIFIC) from brachial to the internal carotid artery
3. Predilatation and stenting
■ 5.0/40 mm Admiral balloon, 135 cm (MEDTRONIC)
■ BeGraft 10/27 mm Covered Stent (Bentley InnoMed)
Friday
Procedural
steps
99
Case 91 – LEI 32: male, 72 years (H-C)
Severely calcified SFA-occlusion right, failed recanalization attempt
Clinical data: Severe claudication right calf, restpain at night
Rutherford class 3-4
Failed recanalization attempt SFA right 12/2015
Bypass left SFA 2013; CAD with MI and PTCA 2013
Chronic renal insufficiency (GFR 55ml /min); COPD
Risk factors: art. hypertension, current smoker, diabetes mellitus type 2
angiography during failed recanalization attempt 12/2015
severely calcified SFA-occlusion right
popliteal artery stenoses right
Procedural
steps
■ IMA-5F diagnostic catheter (CORDIS/CARDINAL HEALTH)
■ 0.035" soft angled Radiofocus glidewire, 190 cm (TERUMO)
■ 0.035" Supracore guidewire, 190 cm (ABBOTT)
2. Retrograde approach via distal SFA
■ 9 cm 21 Gauge puncture needle (COOK)
■ 0.018" V-18 Control guidewire, 300 cm (BOSTON SCIENTIFIC)
■ 0.018" QuickCross support catheter, 90 cm (SPECTRANETICS)
in case of failure to pass from retrograde:
■ 5.0/40 mm-90cm Pacific balloon (MEDTRONIC) or
3. PTA and stenting from antegrade
■ 6.0/40 mm Admiral Extreme balloon (MEDTRONIC)
■ 5.0 or 6.0/150 mm Supera interwoven nitinol-stent (ABBOTT)
100
Live case transmission performing centres
University Hospital Leipzig,
Germany:
Department
for Interventional Angiology:
Dierk Scheinert
Andrej Schmidt
Sven Bräunlich
Matthias Ulrich
Johannes Schuster
Yvonne Bausback
Sabine Steiner
Daniela Branzan
Holger Staab
Department for Diagnostic
and Interventional Radiology:
Michael Moche
Jochen Fuchs
Tim-Ole Petersen
Sandra Purz
Bernhardt Sattler
Guest-Operators:
Fabio Verzini
(University Hospital Perugia,
Italy)
Andrew Winterbotttom
(Cambridge University
Hospital, UK)
Policlinico Abano Terme, Italy:
Marco Manzi
Mariano Palena
C. Brigato
Universitäts-Herzzentrum
Freiburg • Bad Krozingen,
Germany:
Thomas Zeller
Elias Noory
P. Flügel
Sankt Gertrauden-Hospital,
Berlin, Germany:
Ralf Langhoff
Andrea Behne
M. Boral
N. Jabs
Inselspital - Universitätsspital
Schweizer Herz- und
Gefässzentrum, Bern,
Switzerland:
Nils Kucher
Torsten Fuss
DO Dai Do
V. Makaloski
Iris Baumgartner
Villa Maria-Cecilia-Hospital,
Cotignola, Italy:
Antonio Micari
Fausto Castriota
AZ Sint-Blasius Hospital,
Dendermonde, Belgium:
Koen Deloose,
Lieven Maene
Joren Callaert
Galway University Hospitals,
Galway, Ireland
Gerard J. O’Sullivan
Ian Davidson
University Hospital Heidelberg,
Germany:
Dittmar Böckler
Alexander Hyhlik-Dürr
M. Bischoff
Boris Radeleff
Nikolas Kortes
M. Sumkauskaite
D. Gnutzmann
Natalie Tessendorf
S. Schreiner
C. Ernst
Wellmont CVA Heart Institute,
Kingsport, USA
Christoph Metzger
R. Sakhuja
M. Aziz
St. Franziskus Hospital,
Münster, Germany
Martin Austermann
Arne Schwindt
S. Stahlhoff
N. Abu Bakr
Bernd Gehringhoff
M. Bosiers
P. Cao
Giovanni Torsello
Mount Sinai Hospital,
New York, USA
Prakash Krishnan
Karthik Gujja
Vishal Kapur
Holy Name Medical Center,
Teaneck (NJ), USA:
John Rundback
Kevin Herman
Amish Patel

Guide to Live Case Transmissions

Transcription

Similar documents

Das abdominelle Aortenaneurysma: Indikation