 Welcome to Texas Heart Institute Educational Programs on Innovative Technologies and Techniques. My name is Vaughn Mierkrazier. I'm an international cardiologist at Texas Heart Institute and Baylor CHI Medical Center. The topic of this presentation is laser-assisted transgraphed embolization, an additional option for treating type 2 endolique. Now, type 2 endolique is one of the most frustrating complications after EVAR due to its unpredictability and the need for close surveillance and high endovascular expertise that is required for this repair. The prevalence varies in literature between 10% to 35%. Spontaneous thrombosis occurs in 30% to 60% of patients. This typically occurs within the first six of months after EVAR procedure. However, there is a delayed presentation that is present between 27% to 32% of patients, sometimes for unknown reason, but sometimes due to use of anticoagulants. Rupture rate mortality from meta-analysis can be up to 50%. As far as type 2 endolique is concerned, size of nitrous is a very good predictor of persistent type 2 endolique. There is so-called simple type, where a small cavity has ingress and egress vessel like pseudo-angioresms and frequently can close spontaneously after a certain length of follow-up. Then there is a complex type where there are multiple ingress and egress vessels similar like in AV malformations. This type of endolique frequently persists. There are several issues related to transarterial embolization of type 2 endolique. As we can see here in this particular patient, this patient had an EVAR procedure, and a six-month follow-up developed a type 2 endolique from a communication between the superior mesenteric artery and the inferior mesenteric artery. This patient underwent endoluminal repair of his endolique with coil embolization. And as we can see, after coil embolization, there was no longer presence of endolique. However, one year later, the patient developed another endolique. This was again a type 2 endolique from superior renal lumbar arteries. And then he underwent coil embolization of those arteries, as well as coil embolization of several other lumbar arteries in total after four different coil embolization procedures that patients still had persistent type 2 endolique. In this particular scenario, when all the resources are used and it is difficult to find the exact source of endolique frequently, coil embolization of the internal iliac arteries performed, as it's shown here. However, in this particular patient, the problem still persisted, and he needed a surgical repair of his endolique due to further enlargement of his abdominal aortic aneurysm. Now, as far as treatment is concerned, using a variety of endovascular techniques, there has been evidence in the literature that onyx can offer better results for treatment of type 2 endolique. And this particular report from two institutions, from Massachusetts General and also from Baltimore, show that treatment of persistent type 2 endolique in 68 patients with a variety of techniques, coils, onyx, non-onyx glue, and lumbar ligation showed following results. In their conclusion, secondary intervention for persistent type 2 endolique is associated with success in less than half of the cases. Onyx glue, however, showed better results, particularly when it was used as initial secondary intervention. Now, there are issues with trans-arterial, trans-lumbar, or even anterior embolization of type 2 endolique via endovascular approach. And that could be either due to unusual position of the endolique where no access can be obtained with trans-lumbar puncture or with anterior wall puncture. Dr. Mark Muisson from Milwaukee has pioneered this innovative approach for treatment of type 2 endolique using laser-assisted trans-graphed embolization, or TGE. It's a technique for treatment of type 2 endoliques with use of laser energy to micropuncture the endographed via trans-femoral arterial approach to access the aneurysm sac at the precise site of the endolique nitrous irrespective of its location. Here is information related to the equipment that's being used for treatment of this type 2 endoliques. The technique utilizes laser energy to micropuncture the endographed via trans-femoral arterial approach to access the aneurysm sac. Spectro-netic CVX 300 has been used for his experience and with the use of XML laser fiber that measures 0.9 millimeter in diameter. And we have been also using a flexible or torqueable cathode. One of them is a distino cathode, but there are several other ones available on the market. Typically, we use one of the 0.014 microcatheter compatible wires. Typically, they are hydrophilically coated to enter into the aneurysm sac. And then we use the microcatheter to deploy either coils or use the onyx that is shown here. As far as onyx is concerned, it is ethylene vinyl alcohol co-polymer that is dissolved in dimethyl sulfoxide and it's suspended in macronized tantalum powder. Tantalum powder is used for better visualization of the onyx material during the embolization procedure. It has been originally used for intracranial embolization of the aneurysms in the last several decades, but more recently, it has been used in multiple scenarios for treatment of a variety of peripheral conditions. One of the benefits of this particular product is that it contacts with blood, causes instant solidification while the liquid center continues to flow. It's used with solvent or DMSO, which diffuses away at the time of the procedure. It forms a spongy polymer cast, as it's shown on the right upper corner. Now, onyx has to be mixed in this particular mix. It typically takes about 20 minutes of mixing to mix it appropriately before it's being used. I would like to share with you some of the cases that have been treated with laser-assisted TGE with onyx for treatment of type 2 endoleak. As we can see here on the left-hand side panel, we can see type 2 endoleak that is difficult to treat with any other approach. Here in the middle panel, we can see position of the torqueable catheter in a coaxial manner with the iliac stem graft limb. And laser is activated. And the microcatheter is being advanced through the stem graft to the aneurysmal cavity. And then the wire is being introduced into the aneurysmal catheter. And microcatheter is advanced over the wire. And then onyx is being injected into aneurysmal cavity. As you can see, you can see it flowing in the aneurysmal cavity until the flow stops. And that usually indicates that we have completely excluded the cavity of the endoleak from any communication from the arterial flow. And the final image on the right-hand side shows solidified onyx. And the angiogram reveals no evidence of endoleak from a micro puncture that measured 0.9 millimeters in diameter with laser fiber. There is no need for deployment of any endographed within the stem graft to prevent any type of endoleak. So we can see here pre-embolization maximum aortic aneurysm diameter was 7.4 centimeters. And we can see type 2 endoleak. And then the right-hand side, we can see at 6-month follow-up that the aneurysm diameter has shrunk to 5.7 centimeters in diameter. We can see solidified onyx at the side of the previous endoleak and no evidence of any additional endoleak. Here is another patient of ours that had type 2 endoleak. And after stem graft procedure, as we can see, marked with a red arrow in the left panel. And then in the middle panel, we can see after the placement of the laser fiber and the microcatter into the aneurysm cavity injection of the onyx material. On the right-hand side, we can see the completion image where the onyx has solidified. And here we can see on the left-hand side, the final completion angiogram without any evidence of type 2 endoleak. And we have also a sceniographic image on the right-hand side showing excellent result and no evidence of type 2 endoleak. Here's another patient with a different stem graft with type 2 endoleak that is marked with a blue arrow. And then after placement of the onyx material in the aneurysm cavity, there is no evidence of any additional endoleak. And at a 12-month follow-up, we can see mark with onyx arrows on the CT, no evidence of endoleak. We have published with Mark Muizen our experience and their experience on TGE treatment with onyx for type 2 endoleak. The study was carried on from March 2011 until May of 2017. And the 32 patients were included. The technical success rate was 98%. And there were no major complications. At one-year follow-up, the CTA revealed 86% decrease or stable abdominal aortic aneurysm diameter. And this was published in the Journal of Vascular Interventional Radiology in 2017. In conclusion, type 2 endoleak is one of the most frustrating complications of EVAR due to its unpredictability and the need for close surveillance as well as high endovascular expertise for this type of repair. TGE with onyx offered easy access to the endoleak. And TGE reduces time and complexity of the procedure. This technique offers improved procedural and midterm results of treatment of type 2 endoleak. However, I believe that longer follow-up in a greater number of patients is needed to prove all benefits of this technique. Thank you very much for your attention.