We present three novel techniques for creation of (1) a steerable sheath, (2) a 4F snare device, and (3) dual anterograde and retrograde double-wire percutaneous transluminal angioplasty access technique using a single femoral puncture. These techniques were conceived and bench-tested in our institution, allowing the utilization of inexpensive equipment for complicated endovascular procedures. They offer (1) controlled navigation, no-touch vessel cannulation and cannulation of angulated vessels, contralateral limb of stent grafts, fenestrations, and branches; (2) a low-profile (4F external diameter) modifiable snare with the ability to expand to the size of an entire aneurysm and the ability to undo the snare in case of blockage with other endovascular material; and (3) in situ sheath inversion for concomitant anterograde and retrograde percutaneous angioplasty with a single femoral puncture.
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