onyx 34 liquid embolic system for treatment of type 1 ... · 4 endoleaks type 1a after chimney...
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Onyx 34 liquid embolic system for
treatment of type 1 endoleaks after
chimney stentgrafts
Christoph A. Binkert, MD, MBA
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Chimney stentgraft technique
Chimney / snorkel / periscope used for
juxtarenal AAA
short proximal necks
Alternative to fenestrated grafts
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Problem of Chimney stentgrafts
Flow through „gutter“
= endoleak type 1a
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Endoleaks type 1a after chimney Scali et al. J Vasc Surg. 2014;60(4):865-73
41 patients (2008-2012) with chimney stentgrafts
Type 1a endoleaks:
1/41 (2.5%) at procedure
3/41 (7.5%) during follow-up (median f-up 18.2 months)
→ total type 1a endoleak 4/41 (10%)
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Endoleaks type 1a after chimney Moulakakis et al. J Vasc Surg. 2012;55:1497-1503
Review of 15 published reports on chimney stentgrafts
93 patients
Type 1a endoleaks:
3/93 (3%) at procedure
10/93 (11%) during follow-up (mean f-up 9 months)
→ total type 1a endoleak 13/93 (14%)
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Treatment options: block the gutter
Coils
(likely incomplete)
Liquids
(complete filling)
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Ethylene vinyl alcohol copolymer
„ONYX“ (Covidien)
Liquid embolic
Slow hardening
starting at surface
Controlled application
Good visibility
(artefacts on CT!)
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ONYX to treat type 1a endoleaks Henrikson et al. Vascular. 2011;19(2):77-81
Successful sealing of a type 1a endoleak
after chimney stentgraft in 4 patients
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Case example
74 y/o male with 6.2cm juxtarenal AAA
Chimney stentgraft 2 years ago
Type 1a endoleak 1 year ago
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Aortogram pre
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Catheter placement into endoleak
Stable catheter position is important
reversed catheter (femoral)
angled catheter (radial)
Coaxial microcatheter into endoleak
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Catheter placement into endoleak
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ONYX injection
start slow
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ONYX injection
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ONYX injection
go with the flow
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ONYX injection
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ONYX injection
origin of IMA
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ONYX injection
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ONYX injection
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ONYX injection
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ONYX injection
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ONYX injection
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ONYX injection
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ONYX injection
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ONYX injection
stop!
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ONYX injection: different views
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Aortogram post
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CT follow-up at 3 months
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ONYX artefacts on CT http://www.cirse.org/index.php?pid=1008
New formula with less tantalum: ONYX 34L
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Amount of ONYX needed Eberhardt et al. J Endovasc Ther. 2014 ;21(1):162-71
Transcatheter embolization 6 patients with type 1 endoleak
after abdominal EVAR
ONYX 34 (because of high viscosity)
Mean amount of ONYX: 11.8 ml (range 3.0- 25.5ml)
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New ONYX 34L for peripheral use
6ml vial
(less vials necessary)
Shake for >10min.
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Take home points
Type 1a endoleaks not uncommon after chimney stentgrafts
ONYX is well suited to treat type 1 endoleaks
Technical tips
stable catheter position
take enough images (different views)
start slow, go with the flow and stop on time
Onyx 34 liquid embolic system for
treatment of type 1 endoleaks after
chimney stentgrafts
Christoph A. Binkert, MD, MBA