Thoracic endografting is a viable option for the octogenarian.

BACKGROUND: The objective of our study is to determine the feasibility of thoracic aortic endografting in octogenarians. METHODS: Between 2000 and 2006 a total of 504 consecutive patients from two high-volume institutions underwent thoracic endoluminal graft repair for various thoracic aortic pathologies. The following devices were used: Gore TAG (W.L. Gore, Flagstaff, AZ); Talent (Medtronic, Minneapolis, MN); and Zenith (Cook, Inc, Bloomington, IN). One hundred one (101 of 504; 20%) patients were octogenarians; 60 males (1.5:1, M:F) with a mean age of 83.7 years. Indications for intervention included the following: atherosclerotic aneurysms, 75 (75 of 101, 74%); acute and chronic dissections, 11(11 of 101, 11%); penetrating aortic ulcers, 9 (9 of 101, 9%); contained ruptures, 5 (5 of 101, 5%); and 1 transection (1 of 101, 1%). Mean length of follow-up was 3.4 +/- 2.1 years. RESULTS: No intraoperative deaths were noted. Thirty-day mortality was 10% (10 of 101 patients) with an overall late mortality of 26.7% (27 of 101 patients). Mean hospital stay was 6.3 days. A total of 12 neurologic events were noticed: 2 paraplegia (2 of 101, 2%); 4 paraparesis (4 of 101, 4%), 3 with full recovery; and 6 (6 of 101, 6%) cerebrovascular accidents with full recovery in half. A total of 15 endoleaks (15 of 101, 15%) were seen and, in 11, interventions were required. CONCLUSIONS: Our data suggest that technical success is high and age-specific outcomes in this group of patients are favorable. Further studies are warranted.

Endovascular repair of the thoracic aorta in octogenarians.

BACKGROUND: To evaluate the feasibility and safety of thoracic endografting in the octogenarian population. METHODS: Between February 2000 and August 2005, 249 patients with a mean age of 69+/-12.3 years (range 23-91) underwent thoracic endografting. Forty-four patients (27 males and 17 females) were octogenarians with a mean age of 84+/-2.7 years. Indications for intervention included: atherosclerotic aneurysms (26/44, 59%), acute and chronic dissections (9/44, 20.5%), penetrating aortic ulcers (6/44, 14%) and contained rupture (3/44, 7%). RESULTS: Endovascular repair was achieved in all octogenarian patients (44/44, 100%). Mean length of stay was 4.7+/-3.6 days. Two cardiac-related deaths and 1 retrograde dissection death occurred (3/44, 7%). Complications included hemiparesis (n=2) with full recovery at discharge, groin hematoma (n=1), pneumonia (n=2) and stroke (n=1) [6/44, 11%]. Endoleaks were diagnosed in 3 patients [3/44, 7%] (2 type I, 1 type II) at 30-day follow-up. Two patients developed an endoleak beyond 30 days [2/44, 5%] (1 type I, 1 type II). Two re-interventions were necessary at 30 days (1 type I, 1 type II). Mean follow-up was 22 months and there were no device migrations or aortic ruptures. No statistical differences in overall mortality were noted between octogenarians and non-octogenarians at 30 days (7% vs 6%, p=NS), 12 months (18% vs 13%, p=NS) and 24 months (27% vs 15%, p=NS). However, at 5 years post-procedure, octogenarians had a significantly higher overall mortality than non-octogenarians (32% vs 17%, p=0.038). CONCLUSIONS: Advanced age is not a contraindication to thoracic endografting with favorable short and mid-term outcomes compared to non-octogenarians.

Retrograde type A dissection after endovascular stenting of the descending thoracic aorta. Is the risk real?

OBJECTIVE: Retrograde type A dissection during or after endoluminal graft repair of the descending thoracic aorta is a potentially lethal complication unique to thoracic endografting. Our aim is to increase its awareness and to review possible etiological factors. METHODS: Two hundred and eighty-seven patients with different thoracic aortic pathologies were treated with endovascular prostheses over the last 6 years (February 2000 to March 2006) under a single-site protocol. A retrospective review was conducted to identify any retrograde aortic dissections by both chart and film review. Factors that may have contributed to its formation were also documented. This population was analyzed for the complication of retrograde aortic dissection as well as the factors related to its occurrence. RESULTS: Seven patients (2.4%) with a gender distribution of three males and four females experienced a retrograde type A dissection within this sample at a median of 202 days. The mean age was 74 years (range 53-83). Aortic pathologies included aortic dissections (n=6) and thoracic aortic aneurysm (n=1). There were (n=3) 43% retrograde type A dissections identified within the perioperative period. Balloon angioplasty was performed in 71.4% (n=5). Two female patients (28.6%) had this event identified within their initial hospitalization with fatal consequences. Overall mortality was 57% (n=4) with extension of dissection the primary cause of death n=3 and open surgical repair (n=1) after an extension of retrograde dissection. CONCLUSIONS: Female gender, use of stent-grafts for dissection and possible aggressive balloon angioplasty may play a role in the cause of retrograde type A dissection. A close surveillance program is recommended when using thoracic endografts outside the recommended device instructions for use.

Endoluminal stent graft repair of aortobronchial fistulas.

OBJECTIVE: To describe our experience with endoluminal stent graft repair of aortobronchial fistulas. METHODS: We reviewed the records of patients treated with endoluminal stent grafting of aortobronchial fistulas at a private teaching hospital. All patients underwent the following diagnostic studies: computed tomography, angiography, bronchoscopy, and transesophageal echocardiography. With standard endovascular techniques, two different devices were implanted. RESULTS: Between March 1997 and October 2000, we treated four patients with postsurgical fistulas. The patients were diagnosed with hemoptysis between 3 and 23 years after aortic replacement grafting for thoracic aneurysms. Diagnostic studies varied in their ability to find the fistula. Transesophageal echocardiography most reliably demonstrated the fistula in the patients. All were successfully treated by exclusion with endoluminal stent grafting. The patients had no complications and no further episodes of hemoptysis. CONCLUSION: Endoluminal stent grafting of aortobronchial fistulas is feasible and may become the preferred method of management in patients at high risk.