1. Complex Iliac Case Sahil A. Parikh, MD, FACC, FSCAI Assistant Professor of Medicine Director, Center for Research and Innovation Director, Experimental Interventional Cardiology Laboratory Director, Interventional Cardiology Fellowship Program Harrington Heart & Vascular Institute University Hospitals Case Medical Center Case Western Reserve University School of Medicine Cleveland, Ohio

2. Within the past 12 months, I or my spouse / partner have had a financial interest / arrangement or affiliation with the organization(s) listed below. Financial RelationshipCompany Grant / Research Support Abbott/IDEV Technologies, Medtronic, Boston Scientific, CR Bard/Lutonix; Abiomed, TriReme Medical, PeriTec Biosciences, NIH Consulting Fees / Honoraria / Advisory Board Abbott, Medtronic, Boston Scientific, CR Bard/Lutonix, St. Jude Medical, Abiomed, Astra Zeneca, Cordis, Terumo, Spectranetics Disclosure Statement of Financial Interest

3. Complex Iliac Case 71yo male with complex past CV history including PCI of LAD and LCx in 1995 followed by CABG x5 with LIMA to LAD, SVGs to OM1/2 and RPDA. Recent NSTEMI with PCI of SVG to OM with DES On further questioning, has Rutherford 3 IC able to walk only 100 feet before stopping for IC (L>R). Patient on DAPT and OMT including BB, ACEI, and statins Unable to participate meaningfully in cardiac rehab due to IC

4. Aortography at Time of SVG PCI

5. Aortography (Unsubtracted)

6. Complex Iliac Case (Continued) Physical examination demonstrates 1+ L femoral pulse, and biphasic dopplerable L DP/PT Laboratory evaluation unremarkable ABIs/PVRs demonstrated L inflow disease with ABI 0.6 at rest with worsening pressures with exertion

7. Complex Iliac Case (Continued) Treatment Plan: Optimize medical therapy Enroll in cardiac rehabilitation Consider revascularization if no significant improvement after rehabilitation

8. Questions? Access site? Sheath type and size? CTO Crossing technique? Stent type and length? When do we stop? Bailout options Post-procedure follow- up?