Annals of Vascular Surgery
Volume 22, Issue 4 , Pages 541-546, July 2008

Long-Term Outcomes of Endoluminal Therapy for Chronic Atherosclerotic Occlusive Mesenteric Disease

  • Richard W. Lee

      Affiliations

    • Center for Vascular Disease, Division of Vascular Surgery and Section of Interventional Radiology, Department of Surgery, University of Rochester, Rochester, NY
    • ,
  • Andrew M. Bakken

      Affiliations

    • Center for Vascular Disease, Division of Vascular Surgery and Section of Interventional Radiology, Department of Surgery, University of Rochester, Rochester, NY
    • ,
  • Eugene Palchik

      Affiliations

    • Center for Vascular Disease, Division of Vascular Surgery and Section of Interventional Radiology, Department of Surgery, University of Rochester, Rochester, NY
    • ,
  • Wael E. Saad

      Affiliations

    • Center for Vascular Disease, Division of Vascular Surgery and Section of Interventional Radiology, Department of Imaging Sciences, University of Rochester, Rochester, NY
    • ,
  • Mark G. Davies

      Affiliations

    • Center for Vascular Disease, Division of Vascular Surgery and Section of Interventional Radiology, Department of Surgery, University of Rochester, Rochester, NY
    • Center for Vascular Disease, Division of Vascular Surgery and Section of Interventional Radiology, Department of Imaging Sciences, University of Rochester, Rochester, NY
    • Corresponding Author InformationCorrespondence to: Mark G. Davies, Department of Cardiovascular Surgery, Methodist DeBakey Heart and Vascular Center, The Methodist Hospital, 6560 Fannin, Scurlock Tower, Suite 1006, Houston, Texas 77030

Article Outline

Percutaneous interventions for symptomatic chronic mesenteric arterial atherosclerosis are rapidly gaining popularity. This study evaluates the long-term anatomic and functional outcomes of endovascular therapy for chronic atherosclerotic occlusive mesenteric arterial disease at a tertiary referral academic medical center. A retrospective analysis of records from patients who underwent endovascular mesenteric arterial interventions between 1984 and 2006 for chronic mesenteric ischemia was performed. Cases of acute ischemia or cases with associated bowel resection were excluded. Results were standardized to current Society for Vascular Surgery (SVS) criteria. Kaplan-Meier survival analyses were performed to assess time-dependent outcomes. Factor analyses were performed using either a multivariate model for fixed variables or a Cox proportional hazard model for time-dependent variables. Data are presented as mean ± SEM. Thirty-one patients (84% female, average age 70, range 43-90, years) with 41 visceral vessel interventions were identified. Indications for intervention included weight loss >10 kg (61%) and/or postprandial pain (94%). The median SVS comorbidity score was 15 (range 10-24). All had three-vessel athero-occlusive mesenteric disease with a median of two vessels occluded on angiography. The median number of vessels revascularized was two. In all cases stenosis, and not occlusion, was treated. The 90-day mortality was 20% and the major morbidity was 6%. While primary and assisted patency rates for the interventions at 7 years were 69 ± 8% and 72 ± 9%, respectively (mean ± SE, n ≥ 10), cumulative freedom from recurrent symptoms was only 56 ± 10%. Twenty percent of the vessels developed restenosis at a median interval of 0.29 years (range 0.3-2.8), with a freedom from restenosis of 79 ± 8% at 5 years. Fifty percent of these, all with recurrent symptoms, were reintervened successfully with balloon angioplasty and resolution of their symptoms. There was no significant difference between the celiac and superior mesenteric artery outcomes. The correlation of recurrent symptoms and restenosis was significant (p < 0.001). Endoluminal therapy for chronic mesenteric ischemia carries a low morbidity and mortality in a high-risk population. While anatomic patency remains high, long-term therapeutic benefit is not achieved. In its present iteration, endovascular therapy for mesenteric ischemia should be limited to those patients without an open surgical option.

 

Back to Article Outline

Introduction 

While there is a high incidence of visceral vessel atherosclerosis in autopsy studies, symptomatic mesenteric disease is infrequent in most centers. Open revascularization remains the main therapeutic intervention in patients considered fit enough for surgery. However, as the population demographic continues to change and survival in the population with vascular disease improves, endoluminal intervention for chronic mesenteric disease is proving to be an attractive procedure when treating an elderly population presenting with significant comorbidities that place them at significant risk in having open surgery.

The incidence of chronic mesenteric disease is relatively low, and the therapeutic approaches to treatment vary widely between institutions. When compared to open revascularization, endoluminal therapy (i.e., angioplasty and stenting of the celiac or superior mesenteric vessels) is attractive as it carries equivalent short-term patency and lower morbidity. We have previously demonstrated that endoluminal intervention is associated with significantly less morbidity but that it does not carry a survival advantage when outcomes are measured at 90 days and 6 months.1 We and others have also noted a discrepancy between anatomic and functional outcomes in the short term.1 There remains little data on the longer-term outcomes in this select population of patients. The aim of this study was to evaluate the long-term anatomic and functional outcomes of endovascular therapy for chronic atherosclerotic occlusive mesenteric arterial disease at a tertiary referral academic medical center.

Back to Article Outline

Methods 

Study Setting 

This study was performed at a university medical center in a metropolitan area of 1 million persons and an overall catchment area of approximately 5 million in western New York State.

Experimental Design 

A retrospective review of inpatient hospital charts as well as outpatient clinic records covering the years 1984-2006 was performed for all patients who underwent endoluminal therapy for chronic atherosclerotic mesenteric ischemia at the University of Rochester Medical Center. Thirty-one patients were identified who underwent endoluminal therapy and 51 underwent open revascularization during the period of review. Patients with acute mesenteric ischemia or acute exacerbations of chronic, aneurysmal, and nonatherosclerotic mesenteric ischemia were excluded. Several variables were identified in the chart including patient demographics, existing comorbid conditions, sequence and details of treatment, functional outcome, and length of follow-up. A modified medical comorbidity grading system adopted from the Society for Vascular Surgry (SVS) aortic reporting criteria was employed to estimate the severity of comorbid conditions among the patients. Mean patient follow-up was 2.7 ± 1.9 years (median 2.2, range 1-8.4).

Treatment Algorithm 

Patients considered fit for surgery and with two occluded vessels or an occluded superior mesenteric artery (SMA) were offered open surgery. Patients considered unfit or with stenotic disease were offered endoluminal therapy. Fitness for surgery was dependent on the attending of record. To be considered for endoluminal therapy, the patient must have presented with appropriate clinical symptoms of mesenteric ischemia and undergone a duplex ultrasound as well as a contrast imaging study which identified a visceral artery with an ostial atherosclerotic occlusive lesion. Approximately one-quarter of the patients were referred with angiographic diagnosis of ostial occlusive disease. Imaging techniques included duplex ultrasound, computed tomography angiography (CTA), magnetic resonance angiography (MRA), and standard contrast angiography. The criteria followed for identification of arterial stenosis or occlusion using duplex ultrasound adhered to previously described techniques and standards. The patient underwent CTA or contrast angiography if clinical symptoms combined with a >70% ostial stenosis on duplex ultrasound was found on initial examination. Contrast angiography was performed through a femoral or axillary artery approach. The visceral artery with the greatest stenosis was preferentially treated with primary stenting. We opted in general to only treat one vessel as data from open therapy supported a single-vessel approach. No arteries with <50% stenosis were intervened on. Occluded vessels were not treated as we preferred to bypass them if possible. Periprocedural heparin and postprocedural aspirin and clopidrogel were prescribed to all patients receiving a stent. Success of the procedure was determined by anatomic (residual stenosis <30%) and functional (weight gain, symptom relief, and time to recurrent symptoms) criteria. Stented patients were followed every 6 months with duplex ultrasound and office visits. Restenosis with symptoms was observed. Recurrent symptoms prompted a CTA or MRA to evaluate further stenosis or occlusion. Restenosis was treated with balloon angioplasty or further stenting if possible. During follow-up, 98% of patients had at least one duplex ultrasound and 97% of patients had a duplex ultrasound at last follow-up.

Definitions 

Early failure was defined as an inability to cross the lesion at the time of the primary procedure or by the presence of an occlusion or ≥30% restenosis within the first 30 days after the initial procedure. Coronary artery disease was defined as a history of angina pectoris, myocardial infarction, congestive heart disease, or prior coronary artery revascularizations. A patient with chronic renal insufficiency had a serum creatinine level of 1.5 mg/dL (132.6 μmol/L) or greater or was on peritoneal dialysis or hemodialysis. Cerebrovascular disease included a history of stroke, transient ischemic attack, or carotid artery revascularization. A death within 30 days of the procedure was considered procedure-related. A major complication was defined as any event, regardless of how minimal, not routinely observed after endoluminal therapy that required treatment with a therapeutic intervention or rehospitalization within 30 days of the procedure. A modified SVS medical comorbidity grading system originally advised for endovascular aneurysm repair was employed.2

Statistical Analysis 

All statistical analyses were performed on an intention-to-treat basis. Measured values are reported as percentages or means ± 1 standard deviation. Time-dependent variables are presented using Kaplan-Meier analysis and reported using current SVS criteria. Standard errors (SEs) are reported within Kaplan-Meier analyses, and only time points with SE ≤10 and n ≥10 are reported. The log rank test was used to determine differences between Kaplan-Meier curves. Multivariate stepwise regression analysis was used to determine the influence of preprocedural and periprocedural factors on outcomes. The significance level p ≤ 0.10 was used to include or eliminate a covariate from the model. Covariates were considered significantly associated with the outcome if they were included in the final model and their significance level was p ≤ 0.05. Interactions between statistically significant covariates were checked. Logistic regression models were used for outcomes that were measured shortly after the procedure (complications, short-term clinical benefits). The dependence of each covariate on the outcome was first checked separately using the χ2 test. Covariates with a significance level of p ≤ 0.10 were included in the multivariate stepwise analysis.

Back to Article Outline

Results 

Patient Population 

Forty-one endoluminal interventions for mesenteric ischemia were performed on 31 patients (84% females, average age 70, range 43-90, years) during the period of study. Of the 31 patients seen with the diagnosis of chronic mesenteric ischemia due to atherosclerotic occlusive disease, 81% presented with symptoms of postprandial pain and 84% gave a history of a >10 pounds of weight loss. The median duration of symptoms was 14 months, with a median time to diagnosis of 5 months. The median number of diseased (>50% stenosis) or occluded vessels (celiac, mesenteric, and inferior mesenteric arteries) found on final diagnostic imaging was two (one vessel 36%, two vessels 42%, three vessels 22%). The median modified SVS comorbidity score was 14 (range 10-24). Hypertension was the predominant atherosclerotic risk factor (86%), with history of distant or current extensive tobacco use (53%), hyperlipidemia (50%), and diabetes mellitus (22%) being the other most common risk factors identified. Diagnostic evaluation of the patients prior to intervention included conventional angiogram (100%), duplex ultrasound (47%), CTA (22%), and MRA (8%). The remaining patients (23%) were referred to our institution with angiographic studies in hand for intervention.

Intervention 

Eighty-six percent of patients had one vessel treated and the remainder had two vessels treated. Fifteen celiac artery interventions and 26 SMA interventions were performed. No embolic protection devices were employed during the course of this study. In one vessel (2.4%), the lesion could not be crossed, and this was deemed immediate intention-to-treat failure. Therefore, technical success was 97.5%. Median length of stay following intervention was 1 day. The major morbidity was 6%: One patient experienced a groin site hematoma and a second developed an axillary pseudoaneurysm following the procedure; the former was treated conservatively and the latter resected. There were no other complications.

Outcomes 

The 30-day and 90-day mortality rates were 14% and 20%, respectively. Of deaths within 30 days, 25% were attributed to progressive mesenteric ischemia/sepsis and the remainder to cardiovascular causes. Mean patient follow-up was 2.7 ± 1.9 years (median 2.2, range 1-8.4). During follow-up, 48% of patients died, all of cardiovascular causes (two were also identified as having recurrent mesenteric ischemia at the time of their demise). Survival was 77 ± 7% at 1 year and 50 ± 10% at 5 years (Fig. 1A). Primary and assisted patency for the interventions at 7 years was 69 ± 8% and 72 ± 9%, respectively (mean ± SE, n ≥ 10) (Fig. 1B). No factor was identified to influence patency by Cox proportional analysis. Postintervention, 44% of patients developed recurrent symptoms at a median interval of 0.42 years (range 0.3-1.98). By Kaplan-Meier analysis, freedom from recurrent symptoms was 70 ± 8% at 1 year and 56 ± 10% at 5 years (Fig. 1C). Duration of symptoms prior to intervention (relative risk [RR] 0.97, 95% confidence interval [CI] 0.94-0.99, p = 0.01) influenced freedom from recurrent symptoms by Cox proportional analysis. On multivariate analysis, recurrent symptoms were associated with hemodialysis status and absence of statin usage. Twenty percent of the vessels developed restenosis at a median interval of 0.29 years (range 0.3-2.8). By Kaplan-Meier analysis, freedom from restenosis was 85 ± 5% at 1 year and 79 ± 8% at 5 years (Fig. 1C). Female gender (RR 4.22, 1.08-16.11, p = 0.03) was associated with restenosis. Fifty percent of these restenoses, all with recurrent symptoms, were reintervened successfully by balloon angioplasty, with resolution of their symptoms. There was no significant difference in the development of restenosis between the celiac and SMA. The correlation of recurrent symptoms and restenosis was significant (p < 0.001), with an odds ratio of 332.4 (95% CI 1.67-627.8). The development of recurrent symptoms and number of diseased vessels at presentation did not show a correlation. The number of vessels treated at presentation and the development of recurrent symptoms also did not show a correlation.

  • View full-size image.
  • Fig. 1 

    (A) Life-table analysis for patient survival. (B) Life-table analysis for cumulative primary and assisted primary patency. (C) Life-table analysis for freedom from recurrent symptoms and freedom from restenosis. The number at risk value and standard error for each interval are given in the table within the graph. Values are the mean for all data points.

Back to Article Outline

Discussion 

General 

The incidence of chronic mesenteric ischemia is low, at approximately 1 in 100,000,3 although autopsy studies of an unselected population have demonstrated mesenteric atherosclerosis in 35-70% of cases.4 However, the annual number of open revascularizations for the treatment of chronic mesenteric ischemia is estimated to be 340 in nonfederal hospitals throughout the United States.5 A stenosis of >50% is present in 18% of patients older than 65 years, but very few of these patients have symptoms.6 In one natural history study, 82 patients were found to have 50% stenosis of at least one mesenteric artery and were followed for up to 6 years. The overall mortality rate was 40%. Eighty-six percent of patients with significant three-vessel arterial disease had mesenteric ischemia, had other vague abdominal symptoms, or died.7

Patient Population 

The present study has a patient population profile very similar to those reported by others for endoluminal intervention. We specifically excluded any patients with nonatherosclerotic disease or acute mesenteric ischemia to better define a homogenous population. Of note is that >50% of the patients will be dead within 5 years, which allows for a time frame of therapeutic benefit. The survival rates are similar to reports on both open and endovascular revascularization, which have consistently demonstrated no significant survival benefit between the modalities and in fact may simply reflect the clinical acumen of the providers in matching their therapy with the patient. However, with either intervention the survival is not significantly better than those who are treated medically.7 In the present study, we did not find a specific factor that might identify patients more likely to die early in follow-up.

Interventions 

Surgical revascularization for visceral ischemia due to an occluded SMA was first described by Shaw and Maynard8 in 1958; they reported two successful cases of mesenteric thromboendarterectomy. While many advocate multivessel revascularization, single-vessel bypass to the SMA has been very successful, even in patients with multiple-vessel occlusions. Several reports have demonstrated that one-vessel bypasses are successful and have a 70-80% assisted primary patency rate.9, 10, 11 Published reports in the surgical literature document a 19-54% perioperative complication rate and a 0-17% mortality rate with open surgical revascularization.1, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 Meta-analyses of patients undergoing surgical interventions reported 95% initial technical success, with an average of 7% procedure-related deaths, 24% major complications, and patency of approximately 82% after 4 years of follow-up.22 Moreover, the pattern of sustained symptom relief after open revascularization has been high and the need for reintervention at the sites of revascularization has been low.

Since the first reports of percutaneous transluminal angioplasty of the visceral vessels in 1980,23 endovascular therapy for atherosclerotic disease has rapidly expanded in both scope and indication. With the increase in percutaneous approaches to therapy, concern has arisen regarding the durability of treatment. Hallisey et al. reported a 75% primary patency rate at a mean follow-up of 2.3 years.24 Matsumura et al. reported a 29% recurrence rate with endovascular treatment within 1 year of treatment.25 Our data are in accordance with these findings but extend the follow-up to 8 years and demonstrate that the majority of recurrent anatomic and symptomatic issues occur early. It has been suggested that, in selected patients, surgery should be the treatment of choice because it provides better long-term primary patency.17, 26, 27

Functional Outcomes 

When the results of open surgery are retrospectively compared to those of percutaneous angioplasty and stenting, there is a higher incidence of recurrent symptoms after percutaneous therapy.1, 18 Recurrent symptoms can be correlated with restenosis but not with the number of vessels treated. In a recent retrospective review, the Dartmouth group noted an increased rate of restenosis and reintervention in a stent group versus a historical control surgical group.28 However, with reintervention in 53% of patients, 93% were symptom-free at last follow-up, with a significantly smaller periprocedural mortality rate compared to open surgical patients. In addition, the authors pointed out that in one case stent placement allowed sufficient nutritional optimization as to allow a previously poor-risk patient to tolerate a definitive open procedure.28

In comparison to many open approaches, endovascular therapy is often limited to single-vessel revascularization and stenosis rather than occlusion. In this study, the majority of cases had only one significant stenosis in a single vessel intervened on. However, intervention on two vessels has increased since our report comparing our short-term outcomes of open and endoluminal therapy.1 A retrospective study from the Cleveland Clinic in 200118 compared a series of patients who underwent endovascular treatment (primarily for vessel stenosis, not occlusions) with a group of patients undergoing open revascularization and showed that endovascular patients had a higher incidence of symptom recurrence. While single-vessel intervention in the endovascular patients was considered a likely cause, there was no statistical difference between the numbers of vessels treated in the open patients. The present study did not identify the number of vessels treated as a factor influencing symptom recurrence. We did note that the presence of restenosis was associated with symptom recurrence in 50% of patients re-presenting and that greater symptom duration preoperatively did influence the recurrence of symptoms. One can speculate that the introduction of endoluminal therapy has broadened the spectrum of patients who are now offered intervention as both a diagnostic and therapeutic maneuver to include a subset of patients with signs, symptoms, and anatomic findings suggestive of chronic mesenteric ischemia.

Back to Article Outline

Conclusion 

Endovascular revascularization for chronic mesenteric ischemia is a technically successful procedure with low morbidity but is not associated with a durable functional outcome. While anatomic failure in the form of significant stenosis is associated with many cases of recurrent symptoms and will be improved with reintervention, functional outcomes are not as durable as those reported for open revascularization. In its present iteration, endovascular therapy for mesenteric ischemia should be limited to those patients without an open surgical option.

Back to Article Outline

References 

  1. Sivamurthy N, Rhodes JM, Lee D, Waldman DL, Green RM, Davies MG. Endovascular versus open mesenteric revascularization: immediate benefits do not equate with short-term functional outcomes. J Am Coll Surg. 2006;202:859–867
  2. Chaikof EL, Fillinger MF, Matsumura JS, et al. Identifying and grading factors that modify the outcome of endovascular aortic aneurysm repair. J Vasc Surg. 2002;35:1061–1066
  3. Taylor LM, Moneta GL. Intestinal ischemia. Ann Vasc Surg. 1991;5:403–406
  4. Zelenock GB, Graham LM, Whitehouse WM, et al. Splanchnic arteriosclerotic disease and intestinal angina. Arch Surg. 1980;115:497–501
  5. Deerow AE, Seeger JM, Dame DA, et al. The outcome in the United States after thoracoabdominal aortic aneurysm repair, renal artery bypass, and mesenteric revascularization. J Vasc Surg. 2001;34:54–61
  6. Chang JB, Stein TA. Mesenteric ischaemia. Asian J Surg. 2003;26:55–58
  7. Thomas JH, Blake K, Pierce GE, Hermreck AS, Siegel E. The clinical course of asymptomatic mesenteric arterial stenosis. J Vasc Surg. 1998;27:840–844
  8. Shaw RS, Maynard EP. Acute and chronic thrombosis of the mesenteric arteries associated with malabsorption; a report of two cases successfully treated by thromboendarterectomy. N Engl J Med. 1958;258:874–878
  9. McAfee MK, Cherry KJJ, Naessens JM, et al. Influence of complete revascularization on chronic mesenteric ischemia. Am J Surg. 1992;164:220–224
  10. Foley MI, Moneta GL, Abou-Zamzam AMJ, et al. Revascularization of the superior mesenteric artery alone for treatment of intestinal ischemia. J Vasc Surg. 2000;32:37–47
  11. Park WM, Cherry KJ, Chua HK, et al. Current results of open revascularization for chronic mesenteric ischemia: a standard for comparison. J Vasc Surg. 2002;35:853–859
  12. Christensen MG, Lorentzen JE, Schroeder TV. Revascularization of atherosclerotic mesenteric arteries: experience in 90 consecutive patients. Eur J Vasc Surg. 1994;8:297–302
  13. Cunningham CG, Reilly LM, Rapp JR, et al. Chronic visceral ischemia: three decades of progress. Ann Surg. 1991;214:276–288
  14. Hallett JW, James ME, Ahlquist DA, et al. Recent trends in the diagnosis and management of chronic intestinal ischemia. Ann Vasc Surg. 1990;4:126–132
  15. Harward TRS, Brooks DL, Flynn TC, et al. Multiple organ dysfunction after mesenteric artery revascularization. J Vasc Surg. 1993;18:459–469
  16. Hertzer NR, Beven EG, Humphries AW. Chronic intestinal ischemia. Surg Gynecol Obstet. 1977;145:321–328
  17. Johnston KW, Lindsay TF, Walker PM, et al. Mesenteric arterial bypass grafts: early and late results and suggested surgical approach for chronic and acute mesenteric ischemia. Surgery. 1995;118:1–7
  18. Kasirajan K, O'Hara PJ, Gray BH, et al. Chronic mesenteric ischemia: open surgery versus percutaneous angioplasty and stenting. J Vasc Surg. 2001;33:63–71
  19. Kieny R, Batellier J, Kretz J. Aortic reimplantation of the superior mesenteric artery for atherosclerotic lesions of the visceral arteries: sixty cases. Ann Vasc Surg. 1990;4:122–125
  20. Moawad J, Mckinsey JF, Wyble CW, et al. Current results of surgical therapy for chronic mesenteric ischemia. Arch Surg. 1997;132:613–619
  21. Rheudasil JM, Stewart MT, Schellack JV, et al. Surgical treatment of chronic mesenteric arterial insufficiency. J Vasc Surg. 1988;8:495–500
  22. Cluzel P, Auguste M, Galvez V. Traitement endovasculaire des artères digestives. In:  Kieffer E,  Parc E editor. Editions AERCU. Paris: Chirurgie des arteres digestives; 1999;p. 145–153
  23. Uflacker R, Goldany MA, Constant S. Resolution of mesenteric angina with percutaneous transluminal angioplasty of a superior mesenteric artery stenosis using a balloon catheter. Gastrointest Radiol. 1980;5:367–369
  24. Hallisey MJ, Deschaine J, Illescas FF, et al. Angioplasty for the treatment of visceral ischemia. J Vasc Interv Radiol. 1995;6:785–791
  25. Matsumoto AH, Tegtmeyer CJ, Fitzcharles EK, et al. Percutaneous transluminal angioplasty of visceral arterial stenoses: results and long-term clinical follow-up. J Vasc Interv Radiol. 1995;6:165–174
  26. Rose SC, Quigley TM, Raker EJ. Revascularization for chronic mesenteric ischemia: comparison of operative arterial bypass grafting and percutaneous transluminal angioplasty. J Vasc Interv Radiol. 1995;6:339–349
  27. Mateo RB, O'Hara PJ, Hertzer NR, Mascha EJ, Beven EG, Krajewski LP. Elective surgical treatment of symptomatic chronic mesenteric occlusive disease: early results and late outcomes. J Vasc Surg. 1999;29:821–832
  28. Brown DJ, Schermerhorn ML, Powell RJ, et al. Mesenteric stenting for chronic mesenteric ischemia. J Vasc Surg. 2005;42:268–274

 Presented at the Peripheral Vascular Surgery Society Winter Meeting, Park City, UT, January 27-29, 2006.

PII: S0890-5096(08)00087-3

doi:10.1016/j.avsg.2007.09.019

Annals of Vascular Surgery
Volume 22, Issue 4 , Pages 541-546, July 2008

Article Tools

* Image Usage & Resolution