PTA and stenting of iliac and femoro-popliteal lesions

Step 1: Vascular access and cross-over technique

1. Arterial puncture
2. Sheath introduction in Seldinger technique
3. Guide wire access
4. Angiography
5. Forcross-over technique
   1. selection of suitable catheters
   2. selection of suitable wires
   3. replacement of the sheath for a cross-over sheath

Step 2: Passage of arterial stenosis and occlusion

1. Angiography to detect arteriosclerotic lesion
2. Roadmap modus
3. Passage of the lesion with a catheter supported wire under fluoroscopy
4. Subintimal crossing
   1. creation of dissection plane with a wire
   2. subintimal passage of the occlusion with a catheter guided wire
   3. enter true lumen at end of the occlusion
   4. re-entry devices in difficult cases to reenter the true lumen
   5. angiographic control of true lumen
5. Advancement of a suitable balloon and placement within the lesion
6. Inflation of the balloon under fluoroscopy
7. Angiography
8. If necessary, implantation of a stent
9. Completion angiography (including outflow mandatory)
10. Manual compression of puncture site for 15 min, or closure device
11. Compression device

Step 3: Pedal and crural access(for experienced endovascularsurgeons!)

1. Access obtained from above
2. Angiogram from above to image vessel
3. Micropuncture .014 wire access under direct visualization
4. Microcatheter is placed over the wire
5. Cross lesion with the wire
6. Steer the wire into sheath above and externalize the wire
7. Remove microcatheter from below and cross the lesion with this from above
8. Remove the wire from below and apply light pressure to the entry site
9. Place wire with the soft end distally via the microcatheter
10. Deliver final therapy