this video will demonstrate the procedure to perform a left lower extremity diagnostic arteriogram the patient is an elderly female with history of multiple left lower extremity endovascular interventions who presented with a three-day history of rest pain and discoloration of her left fourth and fifth toes ultrasound arterial duplex of the left leg demonstrated an occluded left SFA and a TA with reduced Doppler signals of the remaining vessels the decision was made to perform in our teragrams of her left leg the patient is prepped and draped in standard sterile fashion the plan is to perform a left leg arteriogram with contralateral access care is taken to prep the left groin also in case such access becomes necessary during the procedure this procedure is typically performed under monitored sedation here we see the surgeon giving local infiltration with lidocaine and epinephrine for analgesia at the access site initial access to the vessel is obtained with the use of a mini stick coaxial micro introducer kit under ultrasound guidance the 21 gauge needle with 0.018 guide wire allows arterial access with minimal complications owing to the reduced diameter of the needle and increased tip echogenicity in this image the needle tip can be visualized in the right common femoral artery found lateral to the right common femoral vein once needle access is confirmed through flashback and visualization of the needle tip in the arterial lumen the point o 1/8 wire is advanced into the vessel after the wires successfully advanced into the vessel the fluoroscopy unit in this case a Siemens artist you know is brought into the field to confirm wire placement into the abdominal aorta at this point the five French dilator and sheets from the micro in to do circuit are advanced over the point o when a wire once the five French sheath is in place the point O 1/8 wire and the dilator are removed in exchange for a point O three five Benson wire for access into the contralateral lower extremity you why're placement into the abdominal aorta is once again confirmed with fluoroscopy an 11 blade is then used to make a skin neck over the wire in order to facilitate advancement of a larger five front sheet the mini stick sheath is then removed and a short five French sheath is placed into the right common femoral artery you flashback is confirmed through the sheath side port and the sheath is then flushed with heparin and saline Trust is injected to perform digital subtraction angiography of the access vessel to ensure that there are no access complications a contra catheter is then advanced over the Bentson wire in order to facilitate an abdominal aorta Graham as well as access the contralateral limb the catheter is then positioned in the infirmary no abdominal aorta and DSA is performed with injection of contrast through the sheath to visualize the aorta iliac system in this case the patient is found to have no significant a Horta iliac disease the Contra catheter is then used to select the contralateral iliac Lynne the wire is then advanced into the iliac artery and the conger catheter is pulled back in order to hook it over the aortic bifurcation you the catheter is then carefully advanced over the wire in order to selectively catheterize the left common iliac artery from here the catheter has advanced into the left common femoral artery and DSA is performed in order to visualize the common femoral artery the superficial femoral artery and the profunda femoral artery the image intensifier is then advanced distally in order to visualize the distal sfa and the popliteal artery the image intensifier is then again advanced further down the left lower extremity in order to visualize the anterior tibial artery and the tibial perennial trunk including the peroneal artery and the posterior tibial artery this patient was ultimately found to have long segments occlusion of the SFA and popliteal arteries and occluded peroneal artery and an occluded anterior tibial artery the posterior tibial artery was found to reconstitute distally without any direct inline flow through collaterals from the profunda femoral artery you