Anatomical Variations for Infrapopliteal Intervention
A 64-year-old lady with history of coronary artery bypass surgery and diabetic foot ulcer referred for revascularization of the below the knee arteries. Diagnostic angiography by the ipsilateral approach showed total occlusion before dorsalis pedis artery. We decided to attempt recanalization of CTO in the distal ATA artery to the dorsalis artery to establish ‘‘one straight-line flow’’ to the foot. A 6-F guide catheter was placed to the right popliteal artery through a 6-F antegrade sheath via the right common femoral artery. Crossing of the occlusive lesion from ATA to dorsalis pedis with a 0.014-inch guide wire (Regalia and halberd) supported by a 2 mm long over-the-wire balloon was unsuccessful. Careful reviewing of images revealed probable continuation of Peroneal artery to dorsalis pedis as Type IIIb anatomic variation. Wiring was made along the Peroneal artery tract to the occluded segment into dorsalis pedis artery, followed by balloon dilatation. The totally occlusive lesion was completely recanalized without any significant dissection and residual stenosis. Final angiography showed an excellent result, indicating a Type IIIb variant.
Varicocele embolization in nutcracker syndrome
A 16-year-old adolescent referred with a history of grade 3 left varicocele from two years ago. He had no other diseases, and his urinalysis was normal. Diagnosed as NCS by abdominal ultrasound and MR angiography, he was referred for an endovascular treatment by a urologist according to abnormal semen analysis. Due to NCS, surgery was likely to result in recurrence of varicocele; therefore, endovascular treatment was selected as the preferred method because recurrence is probably unusual with this procedure. Venography revealed increased gradient between inferior vena cava and left gonadal vein, which confirmed the diagnosis of NCS. Also, renal vein injection during Valsalva maneuver revealed severe gonadal vein reflux with retrograde filling of pampiniform plexus. Pushable coils were applied in the distal portion of the draining gonadal vein. Foam sclerotherapy was also done as part of the sandwich method. Amplatzer duct occluder was used for complete proximal occlusion of left gonadal vein.
Port-a-cath snaring to deploy SVC stent
A 43-year-old woman who had colon cancer presented because of a progressive swelling of her face and neck and arms, cyanosis and edema of both hands, and shortness of breath at rest for the last 5 days. She had been receiving subsequent adjuvant chemotherapy, which was administered through a porta-cath placed thorough right subclavian vein in superior vena cava (SVC). Initial diagnostic workup contained a computed tomography scan and DUS, which showed thrombosis of the SVC reaching from the caval confluence of the azygos vein to both brachiocephalic. Vascular compression by a tumor or lymphadenopathy and pulmonary embolism were ruled out.
We performed venography over the right basilic vein and confirmed the diagnosis of an occlusion of the SVC. We placed a multiple-side hole lysis catheter for local thrombolysis for 24 hours. Second-look phlebography on the next day further showed a high-grade residual stenosis of the SVC, which was associated with the tip position of the port-a-cath that had been placed through the right subclavian vein. To ensure unrestrained venous inflow and to prevent secondary SVC syndrome, we decided to perform percutaneous transluminal angioplasty and stenting of the lesion. However, to prevent jailing of the port-a-cath tube by stent placement to keep it functional in case of future chemotherapy and to avoid surgical removal and the need for reimplantation with subsequent risk of thrombosis progression during perioperative pausing of anticoagulation, endovascular repositioning of the port-a-cath tube before percutaneous transluminal angioplasty and stenting was considered in a first approach. Over an 10F sheath access in the right femoral vein the stenosis was passed using a 0.035-inch guidewire for ballooning and stenting of SVC. Afterward, a goose neck snare was inserted over a delivery catheter from right arm venous access and the tip of the port-a-cath was captured in the SVC and pulled back into the right brachiocephalic vein. Then, balloon angioplasty, stent implantation (sinus-XL, 18/60 mm), and post dilation were performed over a 10F sheath access in the right common femoral vein. After successful stent implantation, the snared catheter in right brachiocephalic vein was released and was placed within the SVC stent. Venography at the end of the examination showed an unrestricted venous inflow.
Stenting of Complex Coarctation of Aorta with Aberrant Right Subclavian Artery
A 24-year-old man with history of hypertension referred for coarctoplasty. Surprisingly, right arm blood pressure was significantly lower than left arm pressure.
CT angiography showed coarctation of aorta with aberrant right subclavian artery which originated just after coarctation in descending aorta.
Coarctoplasty was successfully done after passage of V18 guidewire from ascending aorta to descending aorta. Sinus XL, which is a bare self-expandable stent, was deployed from left subclavian artery over stenotic area and aberrant right subclavian artery.
Endovascular approach from radial artery for pulmonary artery stenosis after BT shunt operation
- A 27-year-old lady presented with severe cyanosis and fatigue. Her room air oxygen saturation was 75%. She was Known case of complex congenital heart disease as Double-outlet right ventricle (tetralogy of Fallot type) with long segment of pulmonary artery atresia and large VSD which was not possible for biventricular repair. She underwent palliative modified Blalock–Taussig (BT) shunt surgery when she was 2 y/o. She had no follow up until Echocardiography and CT angiography revealed patent left BT shunt but severe left pulmonary artery stenosis adjacent to shunt.
- Based on CT angiographic images, left radial artery approach was selected. By applying 6F guiding catheter, support catheter, 0.035 hydrophilic wire, V18 wire, 0.014 BMW it was possible to deploy coronary Sapphire balloon and 6m Express renal stent which are compatible with 6F guiding catheter and 0.014 wire. The O2 saturation increased to 86% after the procedure.
Endovascular treatment of pelvic congestion syndrome caused by May-Thurner syndrome
May-Thurner syndrome (MTS) refers to compression of the left common iliac vein (CIV) by the common iliac artery. Although this is typically manifested as acute left lower extremity deep venous thrombosis, MTS is a rare cause of pelvic congestion syndrome. A 41-year-old girl presented with a 2-year history of worsening lower pelvic pains exacerbated during standing. Venography demonstrated pelvic collateralization and left CIV occlusion consistent with MTS. The left CIV was stented with complete radiographic resolution.
Recorded video case
Chimney graft into the left subclavian artery during thoracic endograft placement(TEVAR)
An 88-year-old man with History of open abdominal surgery due to intestinal obstruction with large residual incisional hernia, was referred due to back and flank pain with the diagnosis of Crawford Type 1 TAAA starting at the LSA and extending to the renal arteries
As the LSA bypass was not feasible due to patient’s frailty and old age, we conducted single Chimney TEVAR using a V12 inserted from the Left brachial in subclavian artery, followed by TEVAR from the LCA to the celiac trunk. Due to a severe bend in the descending aorta, procedure was more complicated which was managed by an extra stent graft. The femoral access was managed by Perclose Proglide technique.
Recorded video case
Catheter directed thrombolysis in acute pulmonary embolism
In this video you can watch how to do catheter directed thrombolysis in patients with acute pulmonary embolism who needs thrombolysis.
Phlegmasia cerulea dolens: catheter directed thrombolysis and venous stenting
- A 43-year-old lady with history of oral contraception pill
- She was referred to our center, after injection of 100 mg systemic alteplase due to acute iliofemoral deep vein thrombosis, severe pain and edema.
- After 48 hours of systemic anticoagulation with therapeutic PTT range, left lower extremity deteriorated with severe pain, edema and discoloration.
- Venography, catheter directed thrombolysis and venous stenting was done.
Subclavian coronary steal syndrome: Endovascular treatment
A patient with recent history of coronary artery bypass surgery, presented with left arm claudication and chest pain. CT angiography showed occluded left subclavian artery occlusion. Left distal radial artery (snuff box) and right femoral artery approaches used for revascularization of subclavian artery.
Basic vascular surgery skills
Endoleak Type 2: Transarterial Embolization
In an 86-year-old man with history of endovascular abdominal aortic aneurysm repair (EVAR) about 2 years ago and aneurysmal sac expansion of 2 cm, trans-arterial approach was used to close the endoleak. For embolizing a lumbar artery, the microcatheter was advanced from the internal iliac artery to the iliolumbar artery to the culprit lumbar artery and nidus. Coils and Onyx were applied.