1. Training Iliac / SFA

2. Copyright
The copyright to this document is owned by Mentice AB. No part of this document may be reproduced, retransmitted or sold in any form or by any means to third parties, whether electronically or mechanically, including, but not limited to the way of: photocopying, recording, or information recording and retrieval systems, without the express written permission of Mentice AB.
If you have any questions contact

3. Agenda Presentation Part 1 Hands-on Tools Break Presentation Part 2
Time
Title
Notes
09: :45
Presentation Part 1
General, Access, Tools
09: :15
Hands-on Tools
Clinical tools presentation
10: :30
Break
10: :15
Presentation Part 2
DSA, Intervention, Closure
11: :45
Simulator Warm-up
VIST-C, Usage, Angiography, Case 201 & 203
12:45 – 13:30
Lunch
13: :30
Simulation - Treatment
Case 212 & 213
15: :45
15: :45
Individual Cases - Strategy
5-6 cases with strategy discussion
16: :00
Resume

4. Learning Objectives The learning context will give you
An introduction to endovascular tools used in the cathlab
The basic steps for a peripheral endovascular intervention
Knowledge of common complications and how to handle them
Expected pre-knowledge
Anatomy
Theory on radiation protection
Disease panorama & interventional options, BMT/Endo/Open
LARS: please review

5. Iliac / SFA Stenosis

6. Disease panorama versus indications for treatment
Options
Best Medical Treatment (BMT)
Endovascular
Open surgery
LARS: please review, maybe add an anatomy overview image

7. Stenosis
Common Iliac Artery Superficial Femoral Artery

8. Prior to the Procedure

9. First steps Informed Consent Pre-planning with the Team
Position of the patient (here for a right-handed operator)

10. Vascular Access

11. Vascular Access first important step to a successful intervention
a suboptimal access can make a straight-forward procedure difficult (also for a closure device)
a bad access can threaten the patients life

12. Arterial Puncture Site
superficial and fixed position of the artery
Artery compressible over bone to obtain hemostasis
factors that influence the puncture site
Previously interventions and open procedures (hostile groin)
Site and generalization of vascular disease
Access strategy
size of material

13. Puncture Seldinger technique
Reference.: Acta radiol May;39(5):368-76
Video ”Puncture.wmv”

14. Access – Femoral Approach
Retrograde
Ipsilateral
Contralateral / Crossover / ”over the hill”
Antegrade
”down the barrel”

15. Retrograde Access Common access for iliac interventions
Puncture the common femoral artery (CFA)
Below the inguinal ligament (green lines)
Access to all aortic branches above the iliacs

16. Retrograde - Ipsilateral
Medtronic Images!!! Copyright

17. Retrograde - Contralateral
Cross-over access to iliac and femoral artery
by retrograde puncture of CFA
Technique:
Retrograde puncture
Cross-over catheterization
Guide wire beyond the lesion to contralat CFA
Cross-over sheath (4—6F)
Copyright!!

18. Retrograde - Contralateral
Advantages
Avoid (the more challenging) antegrade puncture
Treatment of contralateral iliac and femoral artery by one puncture
No compression needed on tx site
Disadvantages
Cross-over catheterization has its own obstacles

19. Antegrade Micropuncture technique + US Antegrade puncture of CFA
Difficult access in obese
Indicated in BTK lesions
Cave:
Low puncture may cause
a direct access into the deep femoral artery
guidewire to go to deep femoral artery

20. Other Arterial Access Locations
Popliteal
Pedal
Brachial
Radial

21. Tools

22. Tools Introducer Sheath Guide Wire Catheter
Balloon (Dilatation catheter)
Stent (BE or SE)

23. (Introducer) Sheath Measurement in French F, 1 F = 1/3 mm
Typical (inner) diameters: Range: 4F-8F
Different lengths / shapes
Range: 5-45cm
Shape; numerous in order to faciliate the intubation of tools into vessel orifices
Purpose
Gain stable and safe arterial access supporting the exchange of tools into te vessels
Image of a sheath

24. Guide Wire Measurement in Inch ”, 1” = 25,4 mm
Typical (outer) diameters: 0.014”, 0.018”, 0.035”
Different materials respectively stiffnesses
Hydrophilic / Teflon
Soft / Stiff / Super Stiff
Different lengths / shapes
Range cm/numerous
Purpose
Navigation through arteries
Support of catheters / balloons / stents

25. Guide Wire – Typical Thicknesses

26. Guide Wire – Typical Shapes
flexible tip / soft end (range 0,5-8 cm )
J-shape
long & short
Angled
30⁰, 45⁰,…
Straight
Always use soft end! (In real life)
Never push against resistance!
Never out of sight of your field of view (fluoroscopy) when advancing!
LARS: please suggest the most common tip shapes, maybe with special use for Iliacs/SFA

27. Catheter Measurement in French F, 1 F =1/3 mm
Typical (outer) diameters: range 3-7F
Diagnostic Flush Catheters (holes for contrast injections)
End-hole Catheter
Side-hole Catheter
Guide/guiding Catheter
Different lengths / shapes
Range cm
Purpose
Contrast injections
Guiding through arteries
Flush catheter imagediscription

28. Catheter – Example of Typical Shapes
Straight
Pigtail
Cobra
Multipurpose
Never advance without the wire!
Flush first on the table and then check that no bubbles in the system or syringes!
LARS: please suggest the most common tip shapes, maybe with special use for Iliacs/SFA

29. The Balloon (Dilatation Catheter)
Properties
Compliant /Semi-compliant/ Non-compliant 
Different lengths / sizes
Working length (60-130cm)
Sizes ranges (1,5-14cm), aortic occlusion balloons (up to 40cm)
Characteristics
Material: affects pushability, trackability, kink resistance
Coating: influences crossability, drug-eluting coatings
Design: influences inflation-deflation time
Purpose
Dilatation
Drug Delivery
Bail out

30. OTW vs RX Over the wire (OTW) Rapid exchange (RX)
Guide wire through whole length of shaft
Need for longer guide wires
More expeditious exchange
More pushability and trackability
Rapid exchange (RX)
Guide wire only through distal parts of shaft (max 20cm)
Allow use of shorter guide wires
Faster exchange
Less pushability and trackability

31. The Stent Balloon-expandable vs Self-expandable
Stainless steel/cobolt vs memory alloy
Different lengths / sizes
Length: 13 – 200 mm, diameter: 2.0 – 12 mm
Different introducer- and guide wire- compatibility
Characteristics
Different materials
Different coatings
OTW vs RX
Purpose
Reestablish Blood Flow

32. Stents for the Iliacs
Pros & Cons: Self-expandable (S.E.) vs balloon-expandable (B.E.)
Diameter: vessel size + 1 mm (S.E.), vessel size (B.E.)
Length: adapted to lesion
Prefer 1 long stent over 2 overlapping stents
0.035" vs 0.018" vs 0.014"
" vs SE BE

33. Hands-on Tools

34. DSA – Digital Substraction Angiography

35. DSA – Digital Substraction Angiography
Images are produced using contrast medium by subtracting a 'pre-contrast image' or the mask from later images, once the contrast medium has been introduced into a structure. Hence the term 'digital subtraction angiography'.
Contrast agent is injected
Background (bones, organs, tools) is subtracted (“pre-contrast image” from contrast image)
Just contrast agent (vessels) visible -

36. DSA – Projections for Iliacs
30-40° LAO (left anterior oblique)
30-40° RAO (right anterior oblique)
Visualize the origin of the hypogastrics!
In this example: 2 frames/sec, total contrast volume 15ml, 12ml/sec, psi 1000, injection delay 0.8 sec

37. Steps A guide wire is inserted into the introducer
The guide wire is advanced upon the aortic bifurcation
A pigtail catheter is advanced over the guide wire
Guide wire is removed to allow pigtail catheter gaining its shape and to allow for contrast injections
Prepare for contrastinjection
LARS: please review if it is general enough

38. TEST-Injection Slow (see where you are) Increase flow Watch backflow
Do not empty syringe

39. No Injection If catheter points into plaque/wall
If catheter points into a stenosis
If pressure is damped
If no back-flow

40. Evaluation of the Lesion
Visualisation
Localisation
Stenosis vs occlusion
Length
Diameter
Thrombus
Calcifications
Significant stenosis
Visual or pressure gradient

41. Tips Think before you push Never push hard
Know your technique & material
Monitor the patient
Keep cool
Expect problems and be prepared to solve them
Communicate with your team and with the patient

42. Crossing the Lesion

43. Crossing the Lesion Standard access (Iliac-SFA) Cross-over access
Guide wire with angled or shapeable tip (0,035”)
Standard length (+/- 180 cms)
Support with straight or vertebral-like curved catheter when necessary
Cross-over access
Material for cross-over access (selective catheter, stiff wire, cross-over sheath)
Standard or long guide wire (+/- 260 cms)

44. Considerations Heparin General rule:
100U/kg, 70 kg ex.: U upon access
3.000U upon X-lesion
Adjust to ACT > 250s (300s)
But in general practise one shot IV of IU is good enough without adjusting to ACT!
General rule:
Short lesions - intraluminal
Long lesions - subintimal

45. SFA Lesion

46. Let the wire ”swim” through the stenosis
Crossing the Lesion
Wire
Follow with catheter
Re-entry control
Let the wire ”swim” through the stenosis

47. Intervention - PTA & Stent

48. PTA – Percutaneous Transuminal Angioplasty
Never ever loose your guide wire position (Golden Rule!)
Choose your balloon size carefully according to you DSA or CTA examination
The balloon-catheter is advanced over the wire and placed fully covering the lesion and ideally extending 0,5 cm on both ends (use the radio-opaque markers on the balloon)
The balloon is dilated for about 30 seconds and/or to discomfort for the patient
Repeated dilatations when needed

49. SFA – PTA – Dissection

50. Stenting Never ever loose your guide wire position (Golden Rule!)
The stent-catheter is advanced over the wire and placed fully covering the lesion and ideally extending a few mm:s on both ends
Deploy stent according to IFU
S.E.: Retract outer sheath
B.E.: Dilate with indeflator
Post-dilations when needed

51. SFA – PTA – Dissection - Stent

52. Completion Angiogram

53. Completion Angiogram
Inject contrast through your catheter or introducer sheath
Check run-off and target region (two different angulations)

54. Completion Angiogram Visualize the vascular tree Residual stenosis?
Pressure measurement
Complications?
Interpret images and patients status
Dissection
Embolus
Thrombosis
Etc---

55. Arterial Closure

56. Hemostasis Manual compression Closure device Unappealing and unpopular
Discomfort (patient and operator)
Time-consuming
Closure device
Comfort (patient and operator)
Time-saving

57. Options for Post-Cath Hemostasis
Manual compression
2minutes/Fr -- Diagnostics
3minutes/Fr --Intervention
Post Cath
Manual compression assist products
Hemostatic patches
Compression devices
Vascular Closure Devices VCD

58. Considerations for Selecting a Closure Method
Hostile groins
Earlier Interventions
Type of Interventional Procedure
Access vessel
Bypass?
Vessel Size
Sheath Size
Presence of peripheral vascular disease
Pre-existing or procedure-related complications
Patient allergies and co-morbidities
Anxiety/Collaboration

59. Clinical Benefits of VCD Use
Patients can stay on antiplatelets
Procedure completed in the cath lab
Reliable, fast hemostasis
No need to reverse anti-coagulation therapy
Earlier patient ambulation / discharge
Improved patient care, comfort and satisfaction

60. Hospital Benefits of VCD Use
Increased staff efficiency
Reduced recovery room time
Potential cost saving
Ability to complete additional procedure

61. VCD-Complications Stenosis Laceration
Intra-arterial placement of closure device
Embolization of (part of) closure device
Adventitial closure
Infection
Thrombosis
Femoral neuralgic syndrome
Retainment of (part of) closure device
Periarterial and intra-arterial fibrosis
Cutaneous migration

62. Simulation

63. Simulator Warm-up How to use the simulator How to select tools
How to control fluoro & C-arm
Do an angiography and examine the lesion!
(Case 201 & 203)
Now: 2 persons/simulator, 90 minutes
Tab video of Ben on simulator!!

64. 1. Round: Simulation - Treatment
How to cross the lesion?
How to treat the lesion?
Do an angiography and treat the lesion!
(Case 212 & 213)
13:30-15:30 : 2 persons/simulator

65. 2. Round: Individual Cases - Strategy
You get the Angiographic images!
You suggest the strategy!
15:45-16:45: 2 persons/simulator
Images are provided on the computers (from the customer or from us when wished)