Fig. 2

a Axial hybrid CT images confirmed the two snares (solid arrows) in close proximity to each other, with an adjacent external iliac artery (asterisk). A 21G needle (dotted arrow) was advanced percutaneously through the snare catheters using intermittent CT guidance, allowing a safe trajectory to avoid puncture of the artery and to reduce the potential for damage to adjacent structures; b Additional three-dimensional reformat show the trajectory of the needle (arrows) through the vascular snares; c Switching from CT to fluoroscopy allowed real-time adjustment and advancement of the needle (arrow) through both snares while avoiding the artery, utilizing the “gun-sight” approach without complication (Haskal et al. 1996); d A V-18 wire (solid arrow) was advanced through the needle access and snared through the LCFV access (dotted arrow). The needle was safely removed under fluoroscopy, and through-and-through “flossing” access was achieved with the following technique: the wire and snare were pulled out from the groin access, and a 0.018″ Quick-Cross catheter (Spectranetics, Colorado Springs, CO) was advanced over the wire through the superior snare and then snared from above with the wire removed. The wire was then re-advanced, snared, and pulled out from the neck access site