Thoracic Endovascular Aortic Repair in Octogenarians and Nonagenarians.

BACKGROUND: The oldest segments of the population are expanding rapidly, and the number of thoracic endovascular aortic repairs (TEVARs) performed in the elderly parallels this trend. We describe our institutional TEVAR experience in octogenarians and nonagenarians. METHODS: All patients 80 years and older undergoing TEVAR at a single institution were reviewed using a prospectively maintained database. Baselines demographics, operative details, and outcomes were retrospectively analyzed. RESULTS: Twenty-five octogenarians and nonagenarians (age, 84.8 ± 3.7 years; 64% male) underwent TEVAR between January 2014 and January 2019. The most common preoperative comorbidities were hypertension (n = 24; 96%) and tobacco use (n = 18; 72%), and the mean modified frailty index was 0.32 ± 0.17. Degenerative aneurysms constituted the majority of aortic pathologies (60%), and most patients were symptomatic (64%), with a mean maximal aortic diameter of 62.7 ± 15.6 mm. Endoleaks were noted in 3 (12%) patients. Intensive care unit length of stay was 2.0 (1.5, 3.0) days, and the total length of stay was 5.0 (3.0, 7.0) days. In-hospital mortality was 12% (n = 3), while the overall 30-day mortality was 16% (n = 4). The median follow-up was 469.0 (76.0, 586.0) days. On univariate analysis, the presence of a postoperative complication was associated with a significantly increased risk of 30-day mortality (P < 0.01). CONCLUSIONS: Despite the inherently elevated operative risk among the elderly, this study demonstrates reasonable success rates for TEVAR in octogenarian and nonagenarian patients. In properly selected patients, advanced age alone should not be a prohibitive factor for TEVAR.

Super hydrophilic thin film nitinol demonstrates reduced platelet adhesion compared with commercially available endograft materials.

BACKGROUND: Thin film nitinol (TFN) is a novel material with which to cover stents for the treatment of a wide range of vascular disease processes. This study aimed to show that TFN, if treated to produce a super hydrophilic surface, significantly reduces platelet adhesion, potentially rendering covered stents more resistant to thrombosis compared to commercially available materials. MATERIALS AND METHODS: TFN was fabricated using a sputter deposition process to produce a 5-µ thin film of uniform thickness. TFN then underwent a surface treatment process to create a super hydrophilic layer. Platelet adhesion studies compared surface treated TFN (S-TFN) to untreated TFN, polytetrafluoroethylene, Dacron, and bulk nitinol. In vivo swine studies examined the placement of an S-TFN covered stent in a 3.5 mm diameter external iliac artery. Angiography confirmed placement, and repeat angiography was performed at 2 wk followed by post mortem histopathology. RESULTS: S-TFN significantly reduced platelet adhesion without any evidence of aggregation compared with all materials studied (P < 0.05). Furthermore, in vivo swine studies demonstrated complete patency of the S-TFN covered stent at 2 wk. Post mortem histopathology showed rapid endothelialization of the S-TFN without excessive neointimal hyperplasia. CONCLUSIONS: These results demonstrate that S-TFN significantly reduces platelet adhesion and aggregation compared with commercially available endograft materials. Furthermore, the hydrophilic surface may confer thromboresistance in vivo, suggesting that S-TFN is a possible superior material for covering stents.

Laparoscopic versus open celiac ganglionectomy in patients with median arcuate ligament syndrome.

OBJECTIVE: Median arcuate ligament syndrome (MALS) is a rare disorder characterized by abdominal pain and compression of the celiac artery. Traditional management consists of open MAL division, with or without arterial reconstruction. We present our outcomes using a laparoscopic approach and compare them to patients treated with open MAL division during the same period. METHODS: A retrospective medical records review of all patients with MALS treated at the University of California-Los Angeles from January 1999 to 2009 was performed. RESULTS: Fourteen patients with MALS were treated. All patients underwent an extensive preoperative gastrointestinal (GI) workup with 10 undergoing attempted laparoscopic division of the MAL and celiac ganglion (laparoscopic ganglionectomy [LG]). Two intraoperative conversions were performed for bleeding. Six patients were treated in the open surgery group (open ganglionectomy [OG]). There were no deaths or reoperations in either group. Median time to feeding was 1.0 vs 2.8 days (P≤.05) in the LG and OG groups, respectively, which was statistically significant. Median length of hospitalization was also significantly lower in the LG group compared with the OG group (2.3 vs 7.0 days; P≤.05). Eight patients had LG (100%) and 5 patients had OG (83%) and had immediate symptom resolution (postoperative day 1). Three patients with recurrent symptoms after LG underwent angiography demonstrating persistent celiac stenosis, then an angioplasty was performed. Median follow-up was 14.0 months (2-65 months) for all patients. Three patients who received LG (38%) and 3 patients who received OG (50%) had persistent pain at last follow-up. Six patients in the OG group (100%) and 7 patients in the LG group (88%) had ceased taking chronic oral narcotics at their last follow-up visit. CONCLUSION: Both laparoscopic and open MAL division and celiac ganglionectomy can be safely performed with minimal patient morbidity and mortality. Late recurrence is frequently seen; however, this seems to be milder than the presenting symptoms. The laparoscopic approach results in avoidance of laparotomy and was associated with shorter inpatient hospitalization and decreased time to feeding in our study. Optimal patient selection and prediction of clinical response in these patients remains a challenge.