1. Novel Use Of Microcatheters Techniques To Perform Angiography and Provide Thrombolytics for Acute CLI in EVAR and Aorto-bifem Pts
Michael Wholey, MD MBA
VA Audie Murphy San Antonio
Interventional Radiology
And Vascular Surgery

2. Michael Wholey, MD MBA DISCLOSURES: Consultant: Heraerus Medical
DISCLOSURES:
Consultant: Heraerus Medical
Owner: Attache Group LLC

3. How do you treat these EVAR and Aorto-Bifem cases?
How can you get easily across from a retrograde femoral approach?
How do you deliver diagnostic and infusion catheters into contralateral limb which is diseased/occluded?

4. EVAR and Aorto-Bifem Grafts with Acute Arterial Occlusion
PROBLEM- From a standard contralateral retrograde femoral approach, how to perform:
Diagnostic Angiogram and contralateral lower extremity angiogram
Deliver thrombolysis for acute arterial occlusion
Often, can not advance traditional 0.035” wire and 4-5 French Infusion Catheters
Can not rely on Antegrade Access
Do not know status of ipsilateral limb (without CTA)
Take off of SFA is often too close to graft anastomosis

5. Preferred Catheter(s) for Thrombolysis
Infusion Catheter
Ultrasonic Core
4 Fr, 5 Fr
Lengths
0.035” Wire Platforms
EKOS
Ultrasound Assisted Catheter
6FR
Angiodynamics Uni*Fuse™ Infusion Catheter
Cragg-McNamara™ Valved Infusion Catheter

6. The Problem: How to get across?
72 year old male. Pt s/p AAA repair in remote town, requiring prosthetic graft to bilateral common iliac arteries.
-CAN NOT GET 0.035” REGULAR GLIDEWIRE ACCROSS

7. The Problem: How to get across?
Answer:
-Park a 5 Fr catheter at bifurcation
-Advance Microcatheter (2.8 French) and wire
-Roadmap helps
-Once in place direct hook up with angiographic injector
--(Do not aspirate back)

8. Equipment 5 Fr Diagnostic Catheters Omni™ Flush Angiographic Catheter
-Angiodynamics
BSX Contralateral
SOS Omni® Selective Catheter
-- 5 Fr
” ID
--65 cm length
*Alternatively, 6 Fr Guide Catheter Rim
Rim

9. Current Microcatheters
2.4 Fr, 2.8 Fr braided catheters with 0.014”, 0.016” and 0.018” guidewires
Initially used in IR for embolization and TACE
Coaxially goes through 4-5Fr Diagnostic catheters
Manufacturers
Penumbra Green Latern
BSX Renegade Hi Flo
Terumo Progreat

10. 2.8 Fr Microcatheters BSX High-Flow Renegade Terumo Progreat Remember:
4 cc/sec
Remember: when connecting to injector, do not aspirate back

11. Acute Limb Ischemia in EVAR pt
90 year old male. S/P EVAR two years earlier with 1.4 cm popliteal aneurysm. Presents with sudden pain left leg. Absent pulses. Cold left foot

12. EVAR TPA Case
Non Contrast CT Shows close proximity and sharp angles of the limbs of the Stent Graft

13. Technique
Advancing 5 Fr Omniflush catheter to perform the abd angiogram and then pulling down to assess the limbs with use of 0.035”regular Glidewire
At the bifurcation, park the Omniflush towards the contralateral limb and coaxially advance a high-flow microcatheter (2.8 Fr) and its ” guidewire
Advance the microcatheter first to the common femoral and then into the SFA/Popliteal for start of treatment

14. EVAR TPA Case -Access Left Limb with 0.016” Transend wire
-Exchange for 2.8 Fr Microcatheter with wire
-Advance to Left CFA
-Access Right CFA
-Omni Flush at prox. Portion
-Advance Microcatheter to the proximal left SFA

15. EVAR TPA Case -Popliteal artery abrupt occlusion
-Observe Distal Runofff
-Gently probe for channel with wire
-Posterior Tibial diseased, tapers and stops with lateral plantar branch

16. EVAR TPA Case: Overnight

17. EVAR TPA Case: Overnight
-TPA 1 mg/hr with IV heparinization (700 units/hr) through the microcatheter
-Foot became warmer and pulses returned.
-Placed on anticoagulation and treated later

18. Thrombolysis: EVAR and AAA
In the complete acute arterial occlusions, we will use the high flow microcatheter to deliver the TPA at 1 mg/hour (20-25 cc/hr) in addition to IV heparin ( units/hr via sheath).
Prior to this, we will use a guidewire to gently create a channel through the thrombus if possible.
Patients will be monitored for overnight thrombolytics and returned the next day for assessment.
Depending upon what is seen the next day, antegrade access can be made, elective surgery can be planned, or patient can return for elective endovascular intervention

19. Results: AAA and EVAR Occlusions
Results: We have performed 11 cases with the use of microcatheter
9 cases with diagnostic evaluations to the contralateral limb for EVAR and Aortobifemoral bypass grafts.
2 Thrombolytic cases
We had no minor or major adverse complications from the use of this system.

20. Concept: Smaller is Better
Thrombolytic Therapy Dose:
1 mg/hr of tPA
Mixture 25 mg in 250 cc NS to run at 20 cc/hr
20 cc/hr  cc/sec
So, with such a small rate of infusion, why do you need a catheter almost twice the diameter that results in four-fold reduction in flow:
Remember, Hagen–Poiseuille equation about Radius
Target Artery
6 Fr Catheter
2.8 Fr Catheter

21. Another Treatment with the Microcatheter with EVAR Treatment
Use the micro catheter for microcoil embolization and/or glue of lumbar branch off the internal iliac artery

22. Conclusions
Use of the High Flow Microcatheter has very unique advantages with routine retrograde CFA access in patients with AAA Repair and EVAR:
Able to cross easily through 5 Fr Diagnostic catheter to get into contralateral limb
Quick diagnostic run of the iliacs and femorals
Remember 4 cc/sec for runs with angiographic injector
Able to deliver thrombolytics (tPA) for acute arterial occlusions of the contralateral limb
Able to get into contralateral internal iliac to embolize lumbar arteries for Type II Endoleaks

23. Thank you
Michael Wholey MD MBA
San Antonio, Tx