Field GuideThe knowledge
The hand tools of endovascular surgery, by name, so that you can follow what is being asked for in the angio suite or the hybrid OR and hand over the right thing. The concepts behind them are in the endovascular playbook; this page is the catalogue.
Three measuring systems are used at once, and almost every "will it fit?" question comes down to reading them correctly.
The needle must accept the wire; the wire must pass through the catheter or device; the catheter or device must pass through the sheath's inner diameter; and the sheath's outer diameter determines the hole in the artery and whether the access vessel is big enough. Read every package label in that order.
Over-the-wire devices carry the wire through their whole length: better pushability and the ability to swap wires, but they need a long wire. Rapid-exchange (monorail) devices let the wire exit the shaft a short distance from the tip: a short wire is enough and exchanges are fast, but pushability is less. A balloon label such as "6 x 100 mm, 0.035, 135 cm, 6 Fr" means a 6 mm diameter by 100 mm length, a 0.035 wire, a 135 cm shaft, and a 6 Fr sheath.
| Task | Typical setup |
|---|---|
| Ultrasound-guided femoral access | 21 G micropuncture needle, 0.018 wire, 4 to 5 Fr transitional dilator, then a 0.035 wire and a short sheath |
| Aortogram with runoff | 4 to 5 Fr short sheath, 0.035 wire, 4 to 5 Fr flush catheter on a power injector |
| Contralateral SFA intervention | 6 Fr crossover sheath (about 45 to 55 cm) over a stiff 0.035 wire; 0.035 or 0.018 devices |
| Tibial intervention | 0.014 or 0.018 wire with a support catheter; small-diameter, long balloons on long shafts |
| EVAR | Large-bore sheaths sized to the device, over a super-stiff 0.035 wire, usually with suture-mediated preclose |
Access is the first step and the commonest source of complications, which is why most operators now start small and use ultrasound.
For example Cook Micropuncture, Merit MAK
A small needle and wire, then a coaxial transitional dilator whose inner cannula is removed to accept a 0.035 wire. A misplaced stick leaves a small hole that is easy to hold.
When you'll hear it: "Micropuncture and the ultrasound, please."
Generic (front-wall or Seldinger needle)
The traditional single-step needle that takes a standard wire directly. Larger hole if the stick is wrong, so less used where micropuncture is available.
When you'll hear it: in emergencies and for large, easy targets.
Ultrasound guidance for the femoral, radial, brachial and pedal arteries reduces high and low sticks, back-wall punctures and accidental venous entry. Confirm the needle enters the common femoral artery over the femoral head, then check the position on fluoroscopy before upsizing. The access anatomy is covered in Endovascular.
A sheath holds the puncture open, has a one-way hemostatic valve and a side port for flushing or pressure, and lets you exchange catheters and devices without losing access or bleeding.
For example Terumo Pinnacle, Cordis Avanti+
The standard first sheath for diagnostic work and ipsilateral iliac or femoral intervention.
When you'll hear it: "Put in a 5 French short sheath."
For example Terumo Destination, Cook Flexor Ansel
Goes up and over the aortic bifurcation to sit in the opposite iliac or femoral artery, giving support and a short path for contralateral work. Placed over a stiff wire.
When you'll hear it: "Let's get a 6 French Destination up and over."
For example Cook Flexor Raabe
A long, straight sheath for antegrade access, renal or visceral work, or when extra support is needed without a crossover curve.
When you'll hear it: during antegrade femoral or visceral interventions.
For example Terumo Glidesheath Slender
A thin-walled sheath that gives a larger inner diameter for a smaller outer diameter, reducing radial spasm and occlusion. Usually paired with an antispasmodic and heparin.
When you'll hear it: radial access for visceral or some peripheral cases.
For example Gore DrySeal Flex, Cook Check-Flo Performer
Delivers EVAR and TEVAR components and other big devices. The access vessels must be large enough, and the arteriotomy is closed with preclose sutures or a surgical repair.
When you'll hear it: on every aortic stent graft case.
Generic (Tuohy-Borst, Y-adapter)
A screw-down valve with a side arm that lets a wire or device pass through a guide catheter while you flush or inject.
When you'll hear it: "Tighten the Tuohy," when contrast or blood is leaking back.
The wire is the rail everything else rides on. Wires differ in diameter, length, stiffness, tip shape and coating, and each case usually moves from a soft crossing wire to a stiffer delivery wire.
| Job | What you want | Examples |
|---|---|---|
| Getting in and up | Soft, atraumatic tip that will not dissect | J-tip starter wire, Bentson |
| Crossing | Slippery and steerable | Glidewire (angled or straight), Glidewire Advantage, 0.018 and 0.014 crossing wires |
| Support and delivery | A stiff body with a soft tip | Rosen, Amplatz, Supra Core, Lunderquist (aortic) |
| Small vessels | Low profile, torque control, graded tip load | 0.018 and 0.014 platforms |
Generic, comes in most sheath kits
The curved tip deflects off plaque and branch origins rather than digging in, so it is a safe first wire into the iliacs.
When you'll hear it: "Run the J up into the aorta."
For example Cook
A straight wire with a long, very soft distal segment that buckles rather than perforates. Used to go up through diseased iliacs and through existing stents.
When you'll hear it: "Give me a Bentson."
Terumo
Slippery when wet, steerable with a torque device, and the go-to for crossing tight or tortuous lesions and selecting branches. Stiff versions exist. Too slippery to hold position for bulky devices, so it is usually exchanged.
When you'll hear it: "Angled Glide and a torque device." Keep it wet.
Terumo
A hydrophilic distal segment on a stiffer, coated body, so it crosses like a Glidewire but gives more support for delivering balloons and stents.
When you'll hear it: "Let's cross with an Advantage."
For example Cook
A workhorse support wire with a small J tip that sits safely in branch vessels. Common for delivering iliac and renal stents and crossover sheaths.
When you'll hear it: "Exchange for a Rosen."
For example Boston Scientific Amplatz Super Stiff; Cook Amplatz Extra-Stiff
Stiff enough to straighten tortuous iliacs and track large sheaths and devices. The short floppy tip means the tip position must be watched.
When you'll hear it: "Get me an Amplatz for the sheath."
Cook
The very stiff rail for EVAR and TEVAR delivery. It is placed through a catheter, and its tip is kept in view, because it can injure the arch, the aortic valve or the ventricle if pushed.
When you'll hear it: "Lunderquist up to the arch."
Abbott
A peripheral support wire, stiffer than a Rosen and softer than an Amplatz, used for delivering devices across tortuous segments.
When you'll hear it: during iliac and femoral interventions needing support.
For example Medtronic Wholey, Boston Scientific Magic Torque
Non-hydrophilic wires with good torque control, for steering into a branch while giving moderate support.
When you'll hear it: "Try a Wholey."
Used for tibial and pedal vessels, renal and visceral branches, and low-profile devices. They come in families graded by tip load (grams of force to buckle the tip): low tip loads for tracking, high tip loads for penetrating chronic total occlusions.
For example Boston Scientific V-18 ControlWire, Abbott Command 18
Common for femoropopliteal and tibial work with 0.018 balloons and stents.
When you'll hear it: "Go down with a V-18."
For example Abbott Command 14
For tibial and pedal vessels and small-vessel devices. Often used through a support catheter.
When you'll hear it: below the knee and in pedal loops.
For example Cook Approach CTO; Asahi peripheral wires such as Astato
Stiffer-tipped wires for penetrating the cap of a chronic total occlusion, escalated stepwise from lower to higher tip loads.
When you'll hear it: "Escalate to the 12 gram."
Catheters either deliver a large bolus of contrast (flush catheters) or hook into a particular branch (selective catheters). Each shape exists for a geometry.
Generic; similar designs include Cook Universal Flush
Sits in a large vessel and delivers contrast through many side holes without whipping or injuring the wall. Used for aortograms on a power injector.
When you'll hear it: "Pigtail at L1 for the aortogram."
AngioDynamics
A flush catheter whose curved tip also hooks the opposite common iliac, so the same catheter does the aortogram and then helps walk a wire up and over the bifurcation.
When you'll hear it: "Go up and over with the Omni."
| Shape | Geometry | Typical use |
|---|---|---|
| Kumpe (KMP) | Short, gentle angle | Crossing iliac and femoral lesions; general peripheral selection |
| Berenstein | Short angled tip | Gentle selection, steering a wire through a lesion |
| Multipurpose (MPA) | Mild distal angle | General selection, downgoing vessels |
| Vertebral (VERT) | Slight hockey-stick angle | Arch vessels, peripheral selection |
| Headhunter (H1) | Angled for the arch | Innominate and carotid origins |
| Cobra (C1, C2) | Double curve, downgoing | Renal, celiac, SMA, contralateral iliac |
| Simmons (Sidewinder) 1 to 3 | Reverse curve that must be formed in the aorta | Difficult arch vessels, sharply angled or upgoing origins, crossing a narrow bifurcation |
| SOS Omni | Small reverse curve that forms itself | Renal and mesenteric origins, crossing the bifurcation |
Most shapes come in plain and hydrophilic-coated versions (Terumo's Glidecath line, for example), and in 4 and 5 Fr. Long selective catheters (100 cm or more) are used to reach the opposite leg.
For example Cook CXI, Philips Quick-Cross, Terumo NaviCross, Medtronic TrailBlazer, Boston Scientific Rubicon
Low-profile catheters that run right up to the wire tip to give it backup for pushing through an occlusion, and that allow a wire exchange beyond a lesion without losing position.
When you'll hear it: "Bring the CXI up behind the wire."
For example Terumo Progreat, Boston Scientific Renegade
Run coaxially through a selective catheter into small branches, mainly to deliver coils, plugs or particles for embolization.
When you'll hear it: during type II endoleak and bleeding embolizations.
A flush catheter with a curve (such as an Omni Flush) or a reverse-curve catheter (SOS Omni or Simmons) to hook the left common iliac at the bifurcation, a hydrophilic wire to go up and over, then an exchange for a stiffer wire to carry a long crossover sheath into the left iliac or femoral artery.
Angioplasty balloons are tracked over the wire, positioned across the lesion and inflated with an inflation device (an indeflator) that reads pressure in atmospheres.
For example Boston Scientific Mustang (0.035) and Sterling (0.018); Abbott Armada 35 and 18; BD Ultraverse
Plain old balloon angioplasty, for iliac, femoral and popliteal disease and for vessel preparation before stents or drug-coated balloons.
When you'll hear it: "Open a 5 by 100 Sterling."
For example Boston Scientific Coyote
Low-profile, long balloons for tibial and pedal arteries, often on 150 cm shafts.
When you'll hear it: below the knee in CLTI.
For example Medtronic IN.PACT Admiral, BD Lutonix, Boston Scientific Ranger
Transfer an antiproliferative drug to the vessel wall to reduce restenosis, mainly in the femoropopliteal segment, after the lesion has been prepared with a plain balloon. A 2018 meta-analysis raised a late mortality signal for paclitaxel devices; after further data, the FDA concluded in 2023 that the evidence does not support excess mortality.
When you'll hear it: "Prep with a plain balloon, then the DCB."
For example Boston Scientific cutting balloon; Philips AngioSculpt
Score the plaque in a controlled way so it dilates at lower pressure with less dissection: resistant, fibrotic or recurrent lesions, including vein graft and dialysis access stenoses.
When you'll hear it: on a stubborn waist that will not open.
Shockwave (for example M5+ and S4)
Emitters inside a balloon deliver pulses that crack deep and superficial calcium, so a heavily calcified vessel can then be dilated. Also used to prepare calcified iliacs for large-bore sheaths.
When you'll hear it: "This is too calcified; get the Shockwave."
For example Cook Coda, Medtronic Reliant; ER-REBOA (Prytime Medical)
Mold stent graft seal zones and junctions after deployment, or occlude the aorta for control of a rupture (REBOA or an occlusion balloon through a sheath).
When you'll hear it: "Molding balloon to the neck and the overlaps."
Self-expanding nitinol stents for segments that bend and get compressed; balloon-expandable stents for precise placement and radial strength; covered stents to seal. The comparison table is in Endovascular.
For example Abbott Absolute Pro, BD LifeStent, Boston Scientific Innova
Spring open as the sheath is pulled back and recover their shape after being squashed, which suits the SFA and iliacs. Can foreshorten or jump on release, so they are deployed slowly.
When you'll hear it: "6 by 120 self-expander in the SFA."
Abbott Supera
A woven stent with high radial strength and flexibility, used in the distal SFA and popliteal artery. It needs good vessel preparation and careful deployment so it is neither stretched nor compressed.
When you'll hear it: across the knee joint or in heavy calcium.
For example Cook Zilver PTX, Boston Scientific Eluvia
Self-expanding stents that release paclitaxel to reduce restenosis in the femoropopliteal segment.
When you'll hear it: for longer or recurrent SFA disease.
For example Boston Scientific Express LD, Abbott Omnilink Elite
Mounted on a balloon and expanded to size, landing exactly where placed. Used at ostia (common iliac origins, renal arteries) where precision and strength matter, not in segments that flex.
When you'll hear it: "Kissing balloon-expandable stents at the bifurcation."
Gore Viabahn (self-expanding); Gore Viabahn VBX (balloon-expandable); Getinge iCast (Advanta V12 outside the US); Bentley BeGraft
Stents lined with graft material to exclude an aneurysm or pseudoaneurysm, seal a rupture or perforation, treat in-stent restenosis, and bridge to branch vessels in fenestrated and branched repairs.
When you'll hear it: "Get a covered stent ready" when a vessel ruptures during angioplasty.
TCAR: ENROUTE system (Silk Road Medical, now Boston Scientific). Transfemoral: for example Abbott Xact, Cordis Precise
TCAR uses direct carotid access with flow reversal through a femoral venous sheath for embolic protection. Transfemoral stenting uses a distal filter. Dual antiplatelet therapy is needed after any carotid stent.
When you'll hear it: "Flow reversal on," during TCAR.
For example Medtronic SpiderFX, Abbott Emboshield NAV6, Boston Scientific FilterWire EZ
A basket on a wire placed beyond the lesion to catch debris during carotid stenting, atherectomy or some thrombectomies, then captured and removed.
When you'll hear it: before atherectomy in a single-vessel runoff.
For example BD Venovo, Boston Scientific Vici, Medtronic Abre, Cook Zilver Vena
Dedicated stents for iliofemoral venous obstruction such as May-Thurner, sized with IVUS.
When you'll hear it: after thrombus removal for left iliac vein compression.
EVAR and TEVAR devices are modular: a main body, then limbs and extensions, assembled inside the patient through large-bore sheaths.
Gore Excluder and Excluder Conformable; Medtronic Endurant II and IIs; Cook Zenith Flex; Endologix AFX2 and Alto; Terumo Aortic TREO
The standard infrarenal devices. AFX2 is a unibody graft that sits on the native aortic bifurcation; Alto seals with a polymer-filled ring for short necks; Excluder Conformable can be angled to fit angulated necks.
When you'll hear it: named by brand at the planning conference, sized from the CTA.
For example Gore Excluder Iliac Branch Endoprosthesis
Extends the repair into the common iliac while keeping the internal iliac perfused, avoiding buttock claudication and pelvic ischemia from coiling it.
When you'll hear it: with common iliac aneurysms.
For example Cook Zenith Fenestrated; Gore Excluder Thoracoabdominal Branch Endoprosthesis (FDA approved 2024)
Holes (fenestrations) or side branches line up with the renal and mesenteric arteries, which are then connected with covered bridging stents. Physician-modified grafts are a further option at some centers.
When you'll hear it: for juxtarenal and thoracoabdominal aneurysms.
Gore TAG and Conformable TAG; Medtronic Valiant Navion; Cook Zenith Alpha Thoracic; Terumo Aortic RelayPro. Branch: Gore TAG Thoracic Branch Endoprosthesis
Tube grafts for the descending thoracic aorta: aneurysms, complicated type B dissections, traumatic transections and penetrating ulcers. The thoracic branch device preserves the left subclavian when landing in zone 2.
When you'll hear it: with landing zone and left subclavian planning.
Tools for removing clot from arteries, grafts, veins and the pulmonary arteries, used alone or combined.
Edwards Lifesciences
Passed beyond the clot through an arteriotomy, inflated gently and withdrawn to drag clot out. Typical sizes are 2 to 3 Fr for tibial vessels, 3 to 4 Fr for the popliteal, 4 to 5 Fr for the femoral and SFA, and 5 to 6 Fr for the iliac; the full table is in Open operations. Inflate with saline by feel, not to a set pressure, to avoid injuring the intima.
When you'll hear it: "A 4 Fogarty down the popliteal."
For example Penumbra Indigo system with Lightning
Large-lumen catheters connected to continuous aspiration, increasingly used for acute limb ischemia and pulmonary embolism. Watch the blood loss in the canister.
When you'll hear it: "Let's aspirate first."
Boston Scientific AngioJet
High-speed saline jets fragment and aspirate clot, and can "power-pulse" a lytic into it. It causes hemolysis (red urine) and can cause bradycardia, so run times are limited and hydration matters.
When you'll hear it: with a dark red urine bag afterwards.
Inari (now Stryker) ClotTriever and FlowTriever
Coring and aspiration devices that remove large volumes of clot from iliofemoral veins (ClotTriever) and the pulmonary arteries (FlowTriever) without thrombolytics.
When you'll hear it: for extensive DVT or intermediate- to high-risk PE.
For example Medtronic Cragg-McNamara, AngioDynamics Unifuse; ultrasound-assisted: Boston Scientific EKOS
Placed through the clot to infuse a low dose of thrombolytic over hours, usually in the ICU, with neuro checks, access-site checks and fibrinogen and hemoglobin monitoring per protocol.
When you'll hear it: "Leave a lysis catheter overnight and re-look in the morning."
Devices that remove or modify plaque rather than just displacing it, used mainly in heavily calcified or bulky lesions and as vessel preparation.
Medtronic HawkOne
A rotating blade shaves plaque into a collection chamber in one direction at a time, steered toward the bulk of the disease.
Diamondback 360 (Cardiovascular Systems, now Abbott)
An orbiting crown sands calcium, widening its orbit with speed. Used for calcified femoropopliteal and tibial disease.
Boston Scientific Jetstream
A front-cutting rotating tip with aspiration, which removes debris and some thrombus.
For example Philips Turbo-Elite, AngioDynamics Auryon
Laser energy vaporizes plaque and thrombus, and is used for in-stent restenosis and some occlusions.
Avinger Pantheris
A directional device with an imaging core that shows the vessel layers in real time while cutting.
When a wire crosses an occlusion in the subintimal plane and cannot get back into the true lumen beyond it, a re-entry device aims a needle or wire back in.
For example Cordis Outback Elite, Medtronic Enteer, Boston Scientific OffRoad
Oriented with markers on orthogonal fluoroscopic views, then a needle or wire is directed into the true lumen beyond the occlusion.
When you'll hear it: "We're subintimal and can't re-enter; open an Outback."
Philips Pioneer Plus
An intravascular ultrasound transducer shows the true lumen directly, so the needle is aimed under imaging rather than by fluoroscopic projection.
The alternative strategies, including retrograde pedal or tibial access, are described under planning in Endovascular.
Sometimes the goal is to stop flow: a type II endoleak, a bleeding vessel, an internal iliac before an aortic repair, or a visceral aneurysm.
Pushable: for example Cook Nester and Tornado. Detachable: for example Boston Scientific Interlock, Medtronic Concerto, Penumbra Ruby
Pushable coils are cheaper and pushed out of the catheter; detachable coils can be positioned, withdrawn if wrong, and released precisely. Occlusion depends partly on the patient's ability to clot.
For example Abbott Amplatzer Vascular Plug II and IV; Medtronic MVP
A self-expanding mesh plug that occludes a larger vessel with one device and precise placement, such as an internal iliac artery.
n-butyl cyanoacrylate glue; ethylene vinyl alcohol (Medtronic Onyx)
Fill a space or a network of vessels and do not depend on the patient's clotting, which helps in coagulopathic bleeding. Need experience to control.
Gelatin sponge; particles such as PVA and microspheres
Gelfoam gives temporary occlusion (trauma bleeding); particles occlude small distal vessels (tumors, some bleeding).
Retrievable: for example BD Denali, Argon Option Elite, Cook Celect and Günther Tulip. Permanent: Greenfield, B. Braun VenaTech
Catch emboli in a patient with VTE who cannot be anticoagulated. Retrievable filters should come out once anticoagulation is possible; long dwell times bring migration, perforation, fracture and caval thrombosis.
When you'll hear it: "Who owns the retrieval?" Put it in the discharge summary.
At the end of the case the arteriotomy is closed with a device or held with manual pressure. Device closure lets patients sit up and walk sooner but does not lower the overall complication rate in every setting.
Abbott Perclose ProGlide and ProStyle
Deploys a pre-tied suture through the arterial wall around the arteriotomy. For large-bore sheaths, two devices are usually placed before the sheath goes in (the "preclose" technique) and tied at the end.
When you'll hear it: "Two ProGlides at ten and two."
Terumo Angio-Seal
A small absorbable anchor inside the artery and a collagen plug outside sandwich the hole. It absorbs over weeks to months, which limits early re-puncture at the same spot (see the instructions for use).
When you'll hear it: after diagnostic and small-sheath interventions.
Cordis Mynx
A sealant deployed on the outside of the artery while a small balloon temporarily occludes the hole from inside, leaving nothing in the lumen.
Abbott StarClose SE
A small clip grips the outside of the arteriotomy and closes it.
Teleflex MANTA
A collagen-based device designed for large-bore holes after aortic and structural heart procedures.
Terumo TR Band
Compresses the radial puncture with just enough pressure for hemostasis while keeping the artery patent (patent hemostasis), deflated stepwise per protocol.
When you'll hear it: on the nursing handoff after radial cases.
Hold firm pressure over the arteriotomy, mark the hematoma edge, check the distal pulses and vitals, send a hemoglobin, and call the senior. Think about a retroperitoneal bleed if the puncture may have been high (hypotension and flank pain with a modest groin), a failed device, and a pseudoaneurysm. The playbook is on On call.
Tools that help you see: inside the vessel, without iodine, or with a precisely timed contrast bolus.
For example Philips Visions PV; Boston Scientific OptiCross
An ultrasound transducer on a catheter gives cross-sectional images from inside the vessel: true lumen versus false lumen, vessel diameter for sizing, and stent apposition. Indispensable in venous stenting and helpful in dissection and contrast-sparing work.
Dedicated closed delivery systems
A closed system delivers medical CO2 as a contrast agent without room-air contamination, for patients with renal impairment or contrast allergy. Not used above the diaphragm or in the arm arteries.
Generic
Delivers a set volume at a set rate for aortograms and runoff studies. The operator sets the rate, total volume and pressure limit for the catheter in use; check the catheter's maximum pressure rating.
When you'll hear it: "15 for 30," meaning 15 mL per second for a total of 30 mL.