The document discusses creative endovascular procedures for treating ischemic limb salvage. It describes various techniques including creative arteriography, guidance, access approaches, pathways, and techniques. Retrograde ascending approaches, double approaches, subintimal dissection, wire rendezvous, loop techniques, and trans-collateral techniques are presented. The goal is to obtain direct blood flow to the foot in a creative manner by being flexible and combining different techniques. Recommendations include planning strategies, adapting to each situation, using multi-level work, alternating and combining techniques, being inventive, and only attempting what can be done safely.

1. Creative endovascular procedures
for
ischemic limb salvage
Louay Altarazi,Louay Altarazi,
M.DM.D

2. Before After
Classic procedures;Classic procedures;
Obtaining direct flow to theObtaining direct flow to the
foot through a Tibial arteryfoot through a Tibial artery

3. How to be creative!!How to be creative!!
 Creative ArteriographyCreative Arteriography
 Creative guidanceCreative guidance
 Creative AccessCreative Access
- Retrograde ascending approaches- Retrograde ascending approaches
- Double & multiple approaches- Double & multiple approaches
 Creative pathwaysCreative pathways
- Subintimal dissection- Subintimal dissection
- wires rendez-vous- wires rendez-vous
 Creative techniquesCreative techniques
- Loop technique; pedal planter- Loop technique; pedal planter
- Trans collaterals techniques- Trans collaterals techniques

4. How to be creative!!How to be creative!!
 Creative ArteriographyCreative Arteriography
 Creative guidanceCreative guidance
 Creative AccessCreative Access
- Retrograde ascending approaches- Retrograde ascending approaches
- Double & multiple approaches- Double & multiple approaches
 Creative pathwaysCreative pathways
- Subintimal dissection- Subintimal dissection
- wires rendez-vous- wires rendez-vous
 Creative techniquesCreative techniques
- Loop technique; pedal planter- Loop technique; pedal planter
- Trans collaterals techniques- Trans collaterals techniques

5. 03/05/15
5
Blocked Arteriography

6. How to be creative!!How to be creative!!
 Creative ArteriographyCreative Arteriography
 Creative guidanceCreative guidance
 Creative AccessCreative Access
- Retrograde ascending approaches- Retrograde ascending approaches
- Double & multiple approaches- Double & multiple approaches
 Creative pathwaysCreative pathways
- Subintimal dissection- Subintimal dissection
- wires rendez-vous- wires rendez-vous
 Creative techniquesCreative techniques
- Loop technique; pedal planter- Loop technique; pedal planter
- Trans collaterals techniques- Trans collaterals techniques

7. How to be creative!!How to be creative!!
 Creative ArteriographyCreative Arteriography
 Creative guidanceCreative guidance
 Creative AccessCreative Access
- Retrograde ascending approaches- Retrograde ascending approaches
- Double & multiple approaches- Double & multiple approaches
 Creative pathwaysCreative pathways
- Subintimal dissection- Subintimal dissection
- wires rendez-vous- wires rendez-vous
 Creative techniquesCreative techniques
- Loop technique; pedal planter- Loop technique; pedal planter
- Trans collaterals techniques- Trans collaterals techniques

8. Duplex Guided AngioplastyDuplex Guided Angioplasty
Advantages
􀁺 No radiation
􀁺 No nephrotoxic contrast
􀁺 Multi-planar, magnification
􀁺 Visualization of arterial wall
􀁺 Good Selection & Placement of : balloon, stent
􀁺 Treatment of complications
􀁺 Adequate Anatomical & Hemodynamic technique
control
And more;

9. Duplex Guided AngioplastyDuplex Guided Angioplasty

10. 03/05/15 10
Plaque Recoil

11. 03/05/15 11
Artery Dissection

12. Complication
Thrombus Formation
Insitu Bypass
Anastomosis P T A

13. How to be creative!!How to be creative!!
 Creative ArteriographyCreative Arteriography
 Creative guidanceCreative guidance
 Creative AccessCreative Access
- Retrograde ascending approaches- Retrograde ascending approaches
- Double & multiple approaches- Double & multiple approaches
 Creative pathwaysCreative pathways
- Subintimal dissection- Subintimal dissection
- wires rendez-vous- wires rendez-vous
 Creative techniquesCreative techniques
- Loop technique; pedal planter- Loop technique; pedal planter
- Trans collaterals techniques- Trans collaterals techniques

14. How to be creative!!How to be creative!!
 Creative ArteriographyCreative Arteriography
 Creative guidanceCreative guidance
 Creative AccessCreative Access
- Retrograde ascending approaches- Retrograde ascending approaches
- Double & multiple approaches- Double & multiple approaches
 Creative pathwaysCreative pathways
- Subintimal dissection- Subintimal dissection
- wires rendez-vous- wires rendez-vous
 Creative techniquesCreative techniques
- Loop technique; pedal planter- Loop technique; pedal planter
- Trans collaterals techniques- Trans collaterals techniques

15. How to be creative!!How to be creative!!
 Creative ArteriographyCreative Arteriography
 Creative guidanceCreative guidance
 Creative AccessCreative Access
- Retrograde ascending approaches- Retrograde ascending approaches
- Double & multiple approaches- Double & multiple approaches
 Creative pathwaysCreative pathways
- Subintimal dissection- Subintimal dissection
- wires rendez-vous- wires rendez-vous
 Creative techniquesCreative techniques
- Loop technique; pedal planter- Loop technique; pedal planter
- Trans collaterals techniques- Trans collaterals techniques

16. retrograde ascending approachesretrograde ascending approaches
 Popleatal
approach

17. Retrograde access
Ped access
Post tib
access Peroneal
access

18. Pedal Retrograde Access

19. Post-tibial Retrograde Access

21. How to be creative!!How to be creative!!
 Creative ArteriographyCreative Arteriography
 Creative guidanceCreative guidance
 Creative AccessCreative Access
- Retrograde ascending approaches- Retrograde ascending approaches
- Double & multiple approaches- Double & multiple approaches
 Creative pathwaysCreative pathways
- Subintimal dissection- Subintimal dissection
- wires rendez-vous- wires rendez-vous
 Creative techniquesCreative techniques
- Loop technique; pedal planter- Loop technique; pedal planter
- Trans collaterals techniques- Trans collaterals techniques

22. How to be creative!!How to be creative!!
 Creative ArteriographyCreative Arteriography
 Creative guidanceCreative guidance
 Creative AccessCreative Access
- Retrograde ascending approaches- Retrograde ascending approaches
- Double & multiple approaches- Double & multiple approaches
 Creative pathwaysCreative pathways
- Subintimal dissection- Subintimal dissection
- wires rendez-vous- wires rendez-vous
 Creative techniquesCreative techniques
- Loop technique; pedal planter- Loop technique; pedal planter
- Trans collaterals techniques- Trans collaterals techniques

23. How to be creative!!How to be creative!!
 Creative ArteriographyCreative Arteriography
 Creative guidanceCreative guidance
 Creative AccessCreative Access
- Retrograde ascending approaches- Retrograde ascending approaches
- Double & multiple approaches- Double & multiple approaches
 Creative pathwaysCreative pathways
- Subintimal dissection- Subintimal dissection
- wires rendez-vous- wires rendez-vous
 Creative techniquesCreative techniques
- Loop technique; pedal planter- Loop technique; pedal planter
- Trans collaterals techniques- Trans collaterals techniques

24. Double approach

25. How to be creative!!How to be creative!!
 Creative ArteriographyCreative Arteriography
 Creative guidanceCreative guidance
 Creative AccessCreative Access
- Retrograde ascending approaches- Retrograde ascending approaches
- Double & multiple approaches- Double & multiple approaches
 Creative pathwaysCreative pathways
- Subintimal dissection- Subintimal dissection
- wires rendez-vous- wires rendez-vous
 Creative techniquesCreative techniques
- Loop technique; pedal planter- Loop technique; pedal planter
- Trans collaterals techniques- Trans collaterals techniques

26. How to be creative!!How to be creative!!
 Creative ArteriographyCreative Arteriography
 Creative guidanceCreative guidance
 Creative AccessCreative Access
- Retrograde ascending approaches- Retrograde ascending approaches
- Double & multiple approaches- Double & multiple approaches
 Creative pathwaysCreative pathways
- Subintimal dissection- Subintimal dissection
- wires rendez-vous- wires rendez-vous
 Creative techniquesCreative techniques
- Loop technique; pedal planter- Loop technique; pedal planter
- Trans collaterals techniques- Trans collaterals techniques

27. How to be creative!!How to be creative!!
 Creative ArteriographyCreative Arteriography
 Creative guidanceCreative guidance
 Creative AccessCreative Access
- Retrograde ascending approaches- Retrograde ascending approaches
- Double & multiple approaches- Double & multiple approaches
 Creative pathwaysCreative pathways
- Subintimal dissection- Subintimal dissection
- wires rendez-vous- wires rendez-vous
 Creative techniquesCreative techniques
- Loop technique; pedal planter- Loop technique; pedal planter
- Trans collaterals techniques- Trans collaterals techniques

28. Subintimal dissection

29. How to be creative!!How to be creative!!
 Creative ArteriographyCreative Arteriography
 Creative guidanceCreative guidance
 Creative AccessCreative Access
- Retrograde ascending approaches- Retrograde ascending approaches
- Double & multiple approaches- Double & multiple approaches
 Creative pathwaysCreative pathways
- Subintimal dissection- Subintimal dissection
- wires rendez-vous- wires rendez-vous
 Creative techniquesCreative techniques
- Loop technique; pedal planter- Loop technique; pedal planter
- Trans collaterals techniques- Trans collaterals techniques

30. How to be creative!!How to be creative!!
 Creative ArteriographyCreative Arteriography
 Creative guidanceCreative guidance
 Creative AccessCreative Access
- Retrograde ascending approaches- Retrograde ascending approaches
- Double & multiple approaches- Double & multiple approaches
 Creative pathwaysCreative pathways
- Subintimal dissection- Subintimal dissection
- wires rendez-vous- wires rendez-vous
 Creative techniquesCreative techniques
- Loop technique; pedal planter- Loop technique; pedal planter
- Trans collaterals techniques- Trans collaterals techniques

31. How to be creative!!How to be creative!!
 Creative ArteriographyCreative Arteriography
 Creative guidanceCreative guidance
 Creative AccessCreative Access
- Retrograde ascending approaches- Retrograde ascending approaches
- Double & multiple approaches- Double & multiple approaches
 Creative pathwaysCreative pathways
- Subintimal dissection- Subintimal dissection
- wires rendez-vous- wires rendez-vous
 Creative techniquesCreative techniques
- Loop technique; pedal planter- Loop technique; pedal planter
- Trans collaterals techniques- Trans collaterals techniques

32. Rendez-vous technique

33. Pedal Rendez-vous technique

34. How to be creative!!How to be creative!!
 Creative ArteriographyCreative Arteriography
 Creative guidanceCreative guidance
 Creative AccessCreative Access
- Retrograde ascending approaches- Retrograde ascending approaches
- Double & multiple approaches- Double & multiple approaches
 Creative pathwaysCreative pathways
- Subintimal dissection- Subintimal dissection
- wires rendez-vous- wires rendez-vous
 Creative techniquesCreative techniques
- Loop technique; pedal planter- Loop technique; pedal planter
- Trans collaterals techniques- Trans collaterals techniques

35. How to be creative!!How to be creative!!
 Creative ArteriographyCreative Arteriography
 Creative guidanceCreative guidance
 Creative AccessCreative Access
- Retrograde ascending approaches- Retrograde ascending approaches
- Double & multiple approaches- Double & multiple approaches
 Creative pathwaysCreative pathways
- Subintimal dissection- Subintimal dissection
- wires rendez-vous- wires rendez-vous
 Creative techniquesCreative techniques
- Loop technique; pedal planter- Loop technique; pedal planter
- Trans collaterals techniques- Trans collaterals techniques

36. How to be creative!!How to be creative!!
 Creative ArteriographyCreative Arteriography
 Creative guidanceCreative guidance
 Creative AccessCreative Access
- Retrograde ascending approaches- Retrograde ascending approaches
- Double & multiple approaches- Double & multiple approaches
 Creative pathwaysCreative pathways
- Subintimal dissection- Subintimal dissection
- wires rendez-vous- wires rendez-vous
 Creative techniquesCreative techniques
- Loop technique; pedal planter- Loop technique; pedal planter
- Trans collaterals techniques- Trans collaterals techniques

37. Loop techniqueLoop technique AnatomyAnatomy

38. 03/05/15 38
Before
After
Pedal arches loopPedal arches loop
recanalizationrecanalization

39. Pedal to planter loopPedal to planter loop

40. Pedal to planter loopPedal to planter loop

41. planter to Pedal to loopplanter to Pedal to loop

42. How to be creative!!How to be creative!!
 Creative ArteriographyCreative Arteriography
 Creative guidanceCreative guidance
 Creative AccessCreative Access
- Retrograde ascending approaches- Retrograde ascending approaches
- Double & multiple approaches- Double & multiple approaches
 Creative pathwaysCreative pathways
- Subintimal dissection- Subintimal dissection
- wires rendez-vous- wires rendez-vous
 Creative techniquesCreative techniques
- Loop technique; pedal planter- Loop technique; pedal planter
- Trans collaterals techniques- Trans collaterals techniques

43. How to be creative!!How to be creative!!
 Creative ArteriographyCreative Arteriography
 Creative guidanceCreative guidance
 Creative AccessCreative Access
- Retrograde ascending approaches- Retrograde ascending approaches
- Double & multiple approaches- Double & multiple approaches
 Creative pathwaysCreative pathways
- Subintimal dissection- Subintimal dissection
- wires rendez-vous- wires rendez-vous
 Creative techniquesCreative techniques
- Loop technique; pedal planter- Loop technique; pedal planter
- Trans collaterals techniques- Trans collaterals techniques

44. How to be creative!!How to be creative!!
 Creative ArteriographyCreative Arteriography
 Creative guidanceCreative guidance
 Creative AccessCreative Access
- Retrograde ascending approaches- Retrograde ascending approaches
- Double & multiple approaches- Double & multiple approaches
 Creative pathwaysCreative pathways
- Subintimal dissection- Subintimal dissection
- wires rendez-vous- wires rendez-vous
 Creative techniquesCreative techniques
- Loop technique; pedal planter- Loop technique; pedal planter
- Trans collaterals techniques- Trans collaterals techniques

45. 03/05/15 45
Before After
Trans-Collaterals DilatationTrans-Collaterals Dilatation
CommunicantsCommunicants
anatomyanatomy

46. PeronealPeroneal
ToTo
Post tibialPost tibial

47. PeronealPeroneal
ToTo
Ant tibialAnt tibial
or pedalor pedal

48. Recommendations
 plan your strategy
 adapt your strategy to the situation
 Multi level work
 Alternate & combine techniques
 Be inventive
 Extreme acrobatics !!
 Do only what you can do
 plan your strategy
 adapt your strategy to the situation
 Multi level work
 Alternate & combine techniques
 Be inventive
 Extreme acrobatics !!
 Do only what you can do

49. plan your strategy

50. adapt your
strategy
to the
situation

51. adapt your strategy
to the situation

52. Before After
Multi levels workMulti levels work

53. Alternate & combine techniqueAlternate & combine techniques
Before After

54. Be inventive
Retrograde transcollaterals approacheRetrograde transcollaterals approache

55. Extreme acrobatics !
Per ArPer Ar
Ped ArPed Ar
ArchesArches
CommunicantCommunicant
Post tib ArPost tib Ar
MedialMedial
planter Arplanter Ar
Transvenous
Bypass >>

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