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264 Other devices and how to use them

undesirability of placing stents in the tibial arter-

ies. When the balloon is inserted into the correct

location, it is inated slowly over the course of

approximately 30 to 60 seconds. is is done so

that the atherotomes or outer wires may correct

themselves and separate along the inner circum-

ference of the blood vessel wall. If further angio-

plasty is required, it is usually appropriate to follow

the scoring or cutting balloon with a standard

angioplasty balloon and to open the caliber of the

blood vessel further, since the cleavage planes have

been made within the plaque or within the scar tis-

sue that represents a lesion. Both scoring and cut-

ting balloons are a little larger in their prole than

plain balloons of equal caliber because the blades

or wires are on the outside of the balloon. Aer

balloon ination, the balloon catheter is aspirated

aggressively in an attempt to shrink it down to its

smallest possible size prior to removal.

Cryoplasty involves cooling of the inated

angioplasty balloon in an attempt to induce apop-

tosis. e idea behind cryoplasty is that cell divi-

sion can be interrupted and potentially even the

process of recurrent stenosis could be diminished

or prevented using cooling of the artery and the

surrounding tissues. ere is a substantial amount

of science behind this but whether or not it actu-

ally decreases long-term rates of recurrent steno-

sis has not been conclusively shown. Cryoplasty is

another potential option that may be used in loca-

tions where stenting is undesirable.

e cryoplasty apparatus includes a balloon

catheter that has multiple layers (Figure 20.9).

When the balloon is inated, the multiple layers

are designed to prevent leakage of nitrous oxide.

Because the balloon has multiple layers, the cali-

ber of the sheath required is either 6-Fr or 7-Fr

depending on the size of the balloon diameter that

Fig. 20.9 Apparatus for

performing cryoplasty.

(A)Amultilayered cryoplasty

balloon in its deﬂated and

inﬂated states. (B) The control

panel connects to the cryoplasty

catheter. (C) A nitrous oxide

canister is used to inﬂate the

balloon.

https://t.me/med1917

Peripheral stent–grafts 265

is desired. e balloon catheter is connected to a

pump and when the balloon is located within the

lesion, the catheter is aspirated to clear the lumen

of any air or nitrogen that may be there. e pump

is then set into action at the press of a button.

Nitrous oxide is pumped into the balloon catheter

and then cooled to −10

C. e balloon is inated

gradually over the course of several seconds and is

inated to a very reproducible level of 8 atm. is

helps to decrease the likelihood that the balloon

could be punctured or ruptured and also helps to

achieve a very even type of dilation. Gradual ina-

tion and the very steady pressure increase over the

course of a couple of minutes helps to minimize

dissection. is minimization of dissection is

something that is apparent when using the cryo-

plasty apparatus. e other piece of the system is a

nitrous oxide canister, which may be placed within

the pump at the appropriate time. Aer angio-

plasty is completed, the catheter must be vented,

and aer it is vented a negative aspiration is drawn.

is helps to empty the balloon and as it empties

the blood ows around it and rewarms the balloon.

Once the balloon is rewarmed, it may be reposi-

tioned for an additional ination. Cryoplasty has

been used quite extensively in the lower extremi-

ties in the supercial femoral, popliteal, and tibial

arteries, especially in locations where stenting is

undesirable.

PERIPHERAL STENT–GRAFTS

Stent–gras have broad applications in relining the

aorta and iliac arteries when treating aneurysmal

disease. ere are several other conditions that

may require stent–gra placement. Stent–gras or

covered stents could be self-expanding or balloon-

expandable. Stent–gras available for peripheral

use include the Viabahn

™

stent–gra, the Fluency

™

stent–gra, t he Wa llgra 

™

, the iCast

™

, the Viaba hn

balloon-expandable stent, and the Lifestream

bal-

loon-expandable covered stent. Allof these devices

have a bulkiness beyond standard stents and require

larger sheaths for placement. e uses for stent–

gras are being evaluated and their indications for

use in the treatment of occlusive disease of the lower

extremity are an active area of investigation. In gen-

eral, the lower extremity arteries may be treated

with self-expanding covered stents to accommodate

the exibility of these arteries. Self-expanding cov-

ered stents, usually Viabahn™, are used to treat pop-

liteal artery aneurysms. Either balloon-expandable

or self-expanding stents may be used in the aor-

toiliac segment to treat iliac occlusive disease or to

perform a completely covered aortoiliac reconstruc-

tion. Parallel gras used as branches in conjunction

with endovascular aortic aneurysm repair may be

performed with either balloon-expandable or self-

expanding gras. When self-expanding covered

stents are used as parallel gras, they are typically

reinforced with bare metal stents to avoid being

compressed.

e Viabahn

™

stent–gra has an indicationfor

use in the SFA (Figure 20.10). It is a nitinol mesh

stent–gra with a polytetrauoroethylene (PTFE)

covering. It is relatively exible and has low

chronicoutward force. It is deployed using a ripcord

style deployment system. Viabahn

™

stent–grasare

Fig. 20.10 Peripheral stent–graft. (A) This

self-expanding stent–graft has a nitinol

skeleton and a PTFE cover and is delivered

on a catheter (Viabahn™). The handle

of the catheter contains a ripcord type

mechanism, which is pulled to release the

graft. (B) After deployment, the graft is

self-expanding and somewhat ﬂexible.

(C)Balloon-expandable covered stents are

also available. The balloon-expandable

stent segments are recognizable and

areheld together longitudinally with PTFE

and covered with PTFE.

https://t.me/med1917

266 Other devices and how to use them

available in lengths from 5 to 20 cm. e diam-

eters in which they are available range from 4 to

10 mm. Viabahn

™

stent–gras require sheath sizes

anywhere from 6-Fr to 9-Fr and the sheath sizing

charts and specic catheter availability should be

consulted prior to any case. When treating a lesion

with Viabahn

™

stent– gras, the aim is to achieve

a seal within the artery and in a gra-to-gra fash-

ion of approximately 3 cm. Viabahn

™

stent–gras

may be oversized slightly, but if they are oversized

too much there will be wrinkling and corrugation

of the material within the area of the lumen of the

blood vessel. e Viabahn

™

stent–gra is prepack-

aged on a delivery catheter that is placed through

the sheath and then, when it is in its proper loca-

tion, the ripcord is pulled and the gra is deployed.

Appropriate measuring of both the length and the

width required should be performed prior to place-

ment of the gra. Viabahn

™

stent–gras have been

used to treat peripheral artery aneurysms through-

out the body including carotid, renal, visceral,

iliac, and popliteal vessels. ey have also been

used to treat occlusive disease in the SFA and the

iliac artery and, occasionally, in other locations.

Aer the stent–gra is placed, balloon angioplasty

is performed, including connections and at the

ends of the gra, to ensure that it is fully expanded.

Patients who are treated with stent–gras are typi-

cally maintained on antiplatelet agents or antico-

agulation and occasionally both.

Other types of stent–gras in the peripheral

arteries include the aforementioned gras. e

Fluency

gra is a nitinol stent covered with a

PTFE. It is stier than the Viabahn

™

stent–gra.

Because it is more rigid, it is useful for relatively

straighter conduit arteries. is is also a useful

device for iatrogenic or traumatic injuries to the

subclavian, supercial femoral, and other arter-

ies. e Wallgra™ is also somewhat rigid and has

handling and placement properties similar to the

Wallstent

™

, but its delivery is larger in caliber due

to the PTFE covering. ere is some length vari-

ability at the time of deployment since the nal

deployed length is dependent on the diameter to

which it is deployed. e contourability is poor as it

remains relatively rigid. e iCast

™

and Viabahn

™

VBX are balloon-expandable metal stents with a

gra material covering. ese are generally shorter

and more rigid than the self-expanding covered

stents and accuracy of placement is quite good

since it is balloon expandable. ey are useful for

vessel artery origin lesions such as the renal, subcla-

vian, or common carotid arteries. Even if vascular

trauma is not a signicant part of the work load, it

is a good idea to have some stent–gras available in

case an injury, traumatic or iatrogenic, presents in

the course of usual vascular practice.

THROMBECTOMY AND

THROMBOLYSIS

e intent with both chemical and mechani-

cal thrombolysis is the removal of thrombotic

material from the vascular system. In the case of

chemical thrombolysis, the thrombolytic agent is

delivered directly into the thrombus. Chemical

thrombolysis has been available for several

decades and has been through various iterations

with dierent agents and approaches. e devel-

opment of mechanical thrombectomy devices has

prompted eorts to optimize treatment by com-

bining chemical and mechanical thrombolysis in

each case for a faster and more complete throm-

bus removal.

Chemical thrombolysis calls for pulse spray

administration of thrombolytic agent directly into

the thrombus, followed by an infusion of the same

agent over a period of hours and up to 24 hours or,

occasionally, a little longer. In the case of mechani-

cal thrombolysis, there are various macerating,

churning, or aspirating type devices that may be

used to disrupt thrombus and remove it. e rela-

tive advantages of chemical thrombolysis are the

avoidance of injury to surrounding tissues and

access of the medication to the thrombus regard-

less of other nearby lesions. In general, this is a

more gentle process than mechanical thromboly-

sis, but it oen takes too long. Longer procedures

are not feasible in the setting of acute ischemic

pain or ischemic organ damage and they expose

the patient to longer intensive care stays, higher

doses of thrombolytic agents, and greater risk of

bleeding. e advantages of mechanical thrombol-

ysis are the ability to quickly debulk the clot bur-

den and restore ow, and to speed the procedure

along and avoid prolonged ischemia and prolonged

chemical thrombolysis sessions. e disadvan-

tages of mechanical thrombolysis are mostly

logistical: investment in equipment and time is

required; during the procedure larger sheaths are

needed; each device has its learning curve; and the

thrombus cannot always be reached. Very oen,

https://t.me/med1917

Thrombectomy and thrombolysis 267

the mechanical thrombolysis debulks the throm-

bus but does not clear it completely. erefore,

thrombolysis procedures are oen performed with

a combination of both chemical and mechanical

thrombolysis; these two techniques are used in

concert to achieve a faster and safer result.

If thrombotic or embolic problems occur dur-

ing an endovascular procedure, the best initial

step to address the problem is aspiration throm-

bectomy (i.e., place a catheter in proximity to the

identied thrombus and aspirate). is is a use-

ful adjunct and is sometimes required on unan-

ticipated occasions. Aspiration may be performed

using a specically designed aspiration catheter or

a small sheath. Several companies make aspiration

catheters (e.g., Export

AP Aspiration catheter).

ese are typically 5-Fr or 6-Fr catheters with an

end-hole for aspiration and a monorail delivery.

Itis useful to have one of these on hand in case an

embolus occurs during a routine procedure.

A commonly used chemical thrombolytic

agent is tissue plasminogen activator (tPA). tPA is

mixed in normal saline at a specic concentration

and administered in a variety of ways. One com-

mon method is as follows. Place a sheath close to

the thrombus. Enter the thrombus with a guide-

wire and pass a catheter over the wire and through

the thrombus. Lace the clot with thrombolytic

agent using rapid injection of the agent directly

into the thrombus. is is performed with a 1-mL

syringe, injecting into multiple locations along the

length of a thrombus while gradually withdrawing

the catheter over the guidewire so that the throm-

bolytic agent can be evenly distributed. is is the

pulse spray technique. Aer this is performed, a

soaker hose-type catheter with multiple side holes

is advanced into the thrombus and the guidewire is

removed in exchange for an end-hole wire, which

can be used to infuse thrombolytic agent into the

distal runo (Fig u re 20.11). Put the guidewire

through the lumen of the soaker hose catheter.

is forces the thrombolytic agent out of the side

holes of the catheter. Two drip infusions are set

up: one through the soaker hose catheter itself and

one through the end-hole guidewire so that the

tip of the wire is also infusing tPA. e tip of the

guidewire is infused so that the runo blood ves-

sel, whether it is in the kidney, in the lower extrem-

ity, or in other locations, may be protected from

thrombus accumulation. Soaker hose catheters can

also be obtained that have a valve on the end so

that the lytic agent does not all runo into the dis-

tal vasculature and miss the thrombosed segment

of artery. Heparin is infused through the side arm

of the entry sheath at a subtherapeutic level to pre-

vent thrombus from accumulating in association

with the sheath.

During infusion with thrombolytic agent, the

patient undergoes intermittent laboratory analysis

including hematocrit, platelet level, thrombin level,

prothrombin time, and partial thromboplastin

time. If the thrombin level drops below 100 IU/mL,

the lytic agent should be stopped. e complica-

tions of chemical thrombolysis increase with the

time required for the infusion and the overall dose.

A typical dosing regimen for tPA for an occluded

lower extremity bypass is to lace the clot with

2–6mg of tPA then run the infusion at 1 mg/hour

for 4 hours and then decrease it to 0.5 mg/hour aer

that. Most of the improvement that can be expected

A B C D

Fig. 20.11 Chemical thrombolysis.

(A)An occlusion of the distal popliteal

and proximal tibial arteries is present.

(B)An antegrade sheath is placed and a

guidewire advanced across the thrombus.

hole soaker hose or thrombolytic therapy

catheter is placed. (D) Thrombolytic agent

is infusing through the side holes and

end hole of the catheter to help dissolve

the thrombus and also maintain patency

ofthe runoff vessel. Heparin is also infused

through the side arm of the sheath to help

prevent new thrombus from forming in the

area of the sheath or catheter.

https://t.me/med1917

268 Other devices and how to use them

will be seen within the rst 8 hours. Typically, if

there is a change clinically or if several hours have

gone by, then it is time to repeat the angiography

and check the progress. Chemical thrombolysis

may be combined with aspiration thrombectomy.

A standard aspiration catheter may be placed over

the guidewire and used to aspirate any thrombus

that can be removed in this manner.

There are several devices available for

mechanical thrombolysis. One commonly used

device with a broad variety of applications

is the AngioJet

™

Peripheral Thrombectomy

System device (Figure20.12). When this device

is used, a rapid spray of heparinized saline is

infused and simultaneously aspirated. This cre-

ates a Bernoulli-type effect, which emulsifies

the clot, converts it into very small particulate,

and allows it to be removed with the effluent

from the catheter. The device has several differ-

ent types of catheters that are geared for blood

vessels of a variety of diameters. Care must be

taken to choose the appropriately sized catheter

and to advance it over the guidewire. As the

catheter approaches the thrombus, the machine

is engaged, the catheter advanced slowly, and the

clot gradually removed.

is device may be used alone or in conjunc-

tion with chemical thrombolysis to help remove

clot. Very oen, a thrombolysis case will be initi-

ated with pulse spray using the AngioJet

™

. is is

done by temporarily occluding the euent from

the catheter so that a small amount of infusion of

lytic agent is placed at high speed and eciency

directly into the clot. Aer waiting a pre-set time,

usually 15–30 minutes, the AngioJet

™

is passed

over the guidewire several times to remove throm-

bus. Aer several passes, interval arteriography

is performed. If thrombus removal is incomplete,

catheter-based chemical thrombolysis is estab-

lished. One major limitation of the AngioJet

™

Fig. 20.12 The Angiojet™ mechanical

thrombectomy catheter. (A) The

mechanical thrombectomy catheter

is passed over the guidewire.

(B) When engaged, the catheter

tip simultaneously provides

administration of ﬂuid and aspiration

of efﬂuent.

A B C

Fig. 20.13 Penumbra thrombus

aspiration device. (A) An occlusion

of the popliteal and proximal tibial

vessels is identiﬁed. (B) An antegrade

sheath is placed. The Penumbra

Aspiration Device catheter with

the soft tip is advanced to the

area of thrombus and the suction

mechanism is engaged. The catheter

can be gently advanced to chase

and aspirate the thrombus. (C) The

catheter is connected to a suction

pump that is specially designed to

accompany the catheter and remove

the thrombus.

https://t.me/med1917

Distal embolic ﬁlters 269

is hemolysis; continued usage causes ongoing

damage to circulating red blood cells and this is

manifested by the patient’s blood-colored urine,

decreased hematocrit, and even hemodynamic

instability. e patient is maintained on full anti-

coagulation during mechanical thrombectomy.

e Penumbra Aspiration Device is a suction or

aspiration device. A smooth and well-engineered

catheter is advanced into the area of thrombus.

Extreme and continuous suction is applied to

remove the thrombus. ere is also the potential

to macerate the thrombus with an associated cath-

eter to help assist with aspiration. e catheter can

be moved to position it in the right location for

thrombus removal and the aspiration catheter tip

is gentle enough that it can be advanced into the

thrombus with minimal risk of arterial injury. is

is particularly useful when thrombus has formed

in a lower extremity artery and the patient is pro-

foundly ischemic, and the time to treat must be as

rapid as possible. ere are dierent sized cath-

eters, including 3-Fr, 6-Fr, and 9-Fr, for dierent

indications.

DISTAL EMBOLIC FILTERS

Distal protection devices, or embolic protection

devices , were developed for use in t he carotid vascu-

lar bed (Fig ure 2 0.14). Other applications include

protection during renal stenting or complex lower

extremity revascularization. Recanalizing or deb-

ulking an occluded SFA stent is another situation

in which a lter may be of value. Likewise, dur-

ing atherectomy of long or heavily calcied SFA

lesions, embolization is a risk and lters probably

play a role in making the procedure safer. Distal

protection devices have some risk and cost of their

own. In the carotid circulation, protection is con-

sidered mandatory during stenting, but distal l-

ters may not provide complete protection for the

brain. It is likely that the lters catch most major

emboli and this makes them useful for the lower

extremity. Distal protection devices were rst

approved for use in the coronary circulation when

there is stenosis within a previously placed coro-

nary vein gra. ere are several approved distal

protection devices for carotid stenting. Some of

Fig. 20.14 Distal embolic protection

devices. (A) The Emboshield NAV6™

is a free wire system comprised of a

0.014-inch guidewire with a 0.019-inch

knob on it near the tip and the self-

expanding ﬁlter held open with nitinol

struts. (B) The AngioGuard

is a ﬁxed

wire system with a short landing zone

and an umbrella-like structure. (C) The

FilterWire EZ™ is a ﬁxed wire system

with an eccentric nitinol hoop and a

windsock.

https://t.me/med1917

270 Other devices and how to use them

them are approved for use along with a concur-

rently used stent such as the Emboshield NAV6

™

and the Accunet

. Other devices, such as the Spider

lter (SpiderFX

™

Embolic Protection Device), are

approved for use with any of the approved stents.

Distal protection devices function by being

placed beyond the lesion prior to treatment. ere

are two competing design concepts: one is a xed

wire system (lter is xed to the guidewire and

the wire and lter are placed together) and one is

a freewire system (wire and lter are separate; rst

the wire is placed and then the lter). e Accunet

and the FilterWire

™

are examples of xed wire

systems, where the lter is xed in place along a

guidewire. A short segment of so directional

wire, which is used to cross the lesion, extends

from the tip of where the lter is xed on the sha

of the guidewire. Once the tip of the wire is across

the lesion, the lter delivery catheter is advanced

until the lter, which is compacted tightly into the

lter delivery catheter, is also across the lesion.

Aer the lter has crossed the lesion, a covering

membrane is withdrawn and this allows the self-

expanding lter to deploy and set its position. e

alternative design, the free wire systems, includes

the Emboshield NAV6

™

and Spider lter. With the

Em b os hi e ld N AV6

™

, a specially designed guide-

wire is passed across the lesion. is guidewire

has a shapable tip and comes in several dierent

wire body strengths. ere is a 0.019-inch diam-

eter knob on the body of the 0.014-inch guidewire

close to the tip and this knob is used as a stop for

the lter to prevent it from going o the end of the

wire. In this case, the wire is placed rst, separate

from the lter. e guidewire behaves more likea

traditional guidewire, without the bulky lter

on the wire during passage. Aer the guidewire

is across the lesion, the lter delivery catheter is

advanced and the lter is deployed along the wire.

e Spider lter is dierent in that it allows the use

of any guidewire that is 0.014 inches in diameter.

Subsequently, a microcatheter is passed over the

initial guidewire of choice, the wire is removed,

and then the lter is placed through the micro-

catheter. e lter is then deployed. During the

procedure the lter is maintained in place. With

the free wire lter systems, it is possible to have

minor wire movement without signicant lter

movement. With the xed wire system, any move-

ment of the wire will also cause movement of the

lter. e xed wire systems permit crossing of the

lesion and placement of the lter in a single step,

whereas the free wire systems require separate

maneuvers for each of these steps.

In each of these systems there is some com-

ponent of nitinol scaolding, which provides for

the self-expanding properties of the lters. e

lters have a specic pore size or a range of pore

sizes. Ingeneral, most of the lters have pore sizes

between 110 microns and 400 microns. ere is a

range of expanded lter diameters, generally from

3 to 8mm, and a range of lter lengths. At the con-

clusion of the procedure the lter is recaptured.

In each case, the lter recapturing catheter is

larger than the delivery catheter, with the rationale

being that once the lesion is treated the lumen will

accommodate a somewhat larger catheter in order

to pass through and capture the lter. In addition,

it is not desirable to squeeze the lter into as small

a diameter as when it is an empty new lter, just in

case the lter is full of debris.

Filters may prevent a disastrous case of untreat-

able distal embolization. However, lters also have

pitfalls. ere is the potential that with the release

of embolic material, ltration will not be complete

or that the embolic material may spill out prior

to retrieval of the lter. An additional concern is

that if the pore sizes in the lter itself are too large,

embolic material may pass through the lter, but if

the pore sizes are too small, it will induce throm-

bus formation and may cause a slow ow situa-

tion. e support structure for the lter is in the

direction of the lesion. When a stent delivery cath-

eter is advanced over the guidewire, if the tip of

the catheter encounters the lter support system,

it may become entangled and irreversibly caught

and necessitate some other type of drastic action

to complete the procedure. Damage to the artery

may occur during lter placement for recapturing.

Placement of the lter delivery catheter itself could

cause embolization. Recapturing the lter may be

challenging in a tortuous anatomy.

Lesions of signicant complexity are being

revascularized using endovascular techniques in

many dierent vascular beds. e potential benet

of using lters in other locations is being explored.

Indications for lters may include renal angioplasty

and stenting, complex lower extremity revascular-

ization, atherectomy cases, subintimal angioplasty

cases, treatment of acute or chronic thrombus for-

mation with mechanical thrombectomy devices,

and during coil embolization cases to prevent distal

https://t.me/med1917

Distal embolic ﬁlters 271

embolization of coils. ere is a risk:benet ratio

associated with the lter when used as an adjunct.

Most of the existing lters have been designed for

coronary or carotid circulations and have not been

designed for renal, lower extremity, or other appli-

cations. e lter systems are somewhat restrictive

with respect to the strength of the guidewire that

is used to support the lter. e lter has a length

that requires a specic landing zone, varying from

2 to 4 cm. is distance of nondiseased artery

distal to the lesion may not be available in every

anatomic bed. e diameter range for each lter

varies, but it is usually 4–7 mm to t with the dis-

tal internal carotid artery. Outside this diameter

range, there are no appropriate lters. e lter

itself may cause damage to the artery in the runo

bed and manipulation of the wire in this area may

also cause damage.

Most of the earlier discussion concerns distal

protection devices. ere are two other types of

protection devices, which are not lters but are

occlusive devices. ese devices provide protec-

tion by using occlusion to either stop prograde

cerebral ow or to reverse it. An example of a distal

occlusion device is the PercuSurge Guardwire

™

which is approved for coronary vein gras.

e guidewire is a hypotube with a lumen in it.

Aballoon is mounted on the tip of the wire and

passed across the lesion. Using a special device,

the hypotube is opened and uid administered to

ll the balloon until occlusion of the distal artery

is achieved. Treatment is undertaken and aer

this is done, an aspiration catheter is passed over

the guidewire with ow at a standstill. e area

is aspirated of any potentially embolic material.

Aer multiple aspirations, the balloon is deated

and the guidewire with the balloon on it removed.

ere is also a proximal occlusion balloon system

(the Mo.Ma

™

Ultra Proximal Cerebral Protection

Device), which may be combined with reversed

ow to achieve distal protection. is is performed

with a transfemoral sheath that is quite sizable, up

to 9-Fr to 11-Fr. e sheath is advanced into the

common carotid artery. e balloon is inated to

stop forward ow in the common carotid artery.

Backbleeding ow from the external carotid

artery is occluded with an occlusion balloon.

Prograde cerebral ow is stopped and the carotid

is aspirated vigorously aer the stent is placed but

before ow is restored.

https://t.me/med1917

PART III

Therapy in speciﬁc vascular beds

21 Brachiocephalic interventions 275

22 Visceral and renal artery interventions 297

23 The infrarenal aorta, aortic bifurcation, and iliac arteries: Advice about balloon

angioplasty and stent placement

311

24 The infrainguinal arteries: Advice about balloon angioplasty and stent placement 329

25 Complex lower extremity revascularization 345

26 Salvage of previous reconstructions 373

27 Hybrid procedures 381

28 Technical aspects of treating aortic aneurysms 391

29 Coiling of peripheral aneurysms 419

30 Puncture site management 427

https://t.me/med1917

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