1. Renal Artery Angioplasty and Stenting with Embolic Protection

2. Technique
If unilateral RA to be treated, puncture ipsilateral CFA so the secondary curve of the guide catheter can abut the contralateral aortic wall for stability
Initial 5F sheath and 5F pigtail catheter for single aortic flush study – localise renal arteries relative to bony landmarks
Exchange sheath for 35cm 8F sheath (if using embolic protection) to maximise guide catheter torque control

3. Technique 8F guide catheter – usually RDC shape
Heparin (ACT > 250s), GTN boluses
Attempt primary passage of embolic filter (eg Angioguard 6-7mm)
If successful, deploy filter in distal MRA
If unsuccessful, use “buddy wire” technique

4. Technique Pre-dilate critical stenoses (eg 4mm monorail balloon)
Introduce BE stent (eg 6-7mm X 12mm)
Consider oblique view to optimally profile renal artery ostium
Deploy stent using semi-compliant balloon, monitoring patient discomfort
With deflated balloon catheter in place, introduce guide catheter so it sits in the stented segment

5. Technique Remove balloon catheter leaving guide catheter in place
Completion angiogram with embolic filter in place
Recapture embolic filter
Completion angiogram with embolic filter removed

6. Technique
Preliminary aortic flush study to localise RAs

7. Technique
Primary passage of distal embolic filter

8. Technique
Stent deployed with semi-compliant balloon

9. Technique
Completion angiogram with filter in place

10. Technique
Completion angiogram with filter removed

11. Embolisation of IMA Type 2 Endoleak

12. Technique
Careful evaluation of CTA to identify origin and orientation of marginal artery off SMA
Retrograde CFA approach
Aortic flush angiography to exclude other causes of endoleak (proximal and distal type 1, type 3)

13. Technique
Selective SMA injections with catheter in proximal SMA (eg 5F C2 NS, Simmons 2)
Important not to have the catheter too distal in SMA as may miss marginal artery origin
Try and select marginal artery origin with 5F catheter (may need coaxial approach – eg 7F Ansel 2, selective 5F catheter)

14. Technique Use co-axial mico-catheter and wire (eg Terumo Progreat)
Manipulate micro-catheter down ascending left colic and into IMA trunk
Embolise IMA trunk (usually microcoils eg Cook 0.018” Tornados) leaving ascending colic and superior rectal arteries in continuity

15. IMA embolisation

16. IMA embolization

17. IMA embolization
Pre-embolisation
Post-embolisation

18. Post IMA embolisation CT