Abstract
BackgroundCarotid angioplasty and stenting (CAS) is often considered as the preferred treatment for severe carotid occlusive disease in patients labelled as "high risk", including those aged 80 or more. We analyzed 30-day stroke risk and death rates after carotid endarterectomy (CEA) for severe symptomatic or asymptomatic carotid disease in patients aged 80 or more, by comparison with the outcome of CAS reported in the recently- published literature.MethodsA retrospective review was conducted on a prospectively compiled computerized database of all primary CEAs performed by a single surgeon at our institution from 1990 to 2003. Descriptive demographic data, risk factors, surgical details, perioperative strokes and deaths, and other complications were recorded.ResultsIn all, 1260 CEAs were performed in 1099 patients; 1145 were performed in 987 patients less than 80 years old, and 115 were performed in 112 patients aged 80 or more. There were 11 perioperative strokes in the 1145 procedures in the younger group, for a stroke rate of 0.8%, and no strokes in the 115 procedures in the older group. The death rates were 0% for the octogenarians and 0.3% for the younger group.ConclusionThe conviction that older age means higher risk needs to be revised. Patients aged 80 or more can undergo CEA with no more perioperative risks than younger patients. Proponents of CAS should bear this in mind before recommending CAS as the best therapeutic option for such patients.
Highlights
Carotid angioplasty and stenting (CAS) is often considered as the preferred treatment for severe carotid occlusive disease in patients labelled as "high risk", including those aged 80 or more
A retrospective review was conducted on a prospectively compiled computerized database of all primary carotid endarterectomy (CEA) performed by a single surgeon at our institution from 1990 to 2003 in symptomatic and asymptomatic patients with high-grade internal carotid artery (ICA) lesions according to the recommendations of the North American Symptomatic Carotid Endarterectomy Trial (NASCET) [1] and the Asymptomatic Carotid Atherosclerosis Study (ACAS) [3]
The ICA lesion was diagnosed on preoperative traditional digital subtraction angiography (DSA) during the earlier part of this experience, while duplex ultrasonography scan (DUS) was the only preoperative ICA imaging study performed in most patients from mid-1998 onwards, combined in selected patients with either magnetic resonance (MR) angiography, computed tomography (CT) angiography, or traditional arteriography
Summary
Carotid angioplasty and stenting (CAS) is often considered as the preferred treatment for severe carotid occlusive disease in patients labelled as "high risk", including those aged 80 or more. Though many single-centers studies reported that CAS can be performed with acceptable periprocedural complication rates [11], advanced age was considered a significant predictor of periprocedural neurological events after unprotected and protected CAS procedures in several recently-published large single- and multicenter trials [810]. This finding is odd, but the authors did not attempt to explain why the outcome of CAS should be significantly worse in older than in younger patients. Reanalyzing outcome in the multicenter surgical trials on the basis of age revealed that patients aged ≥ 75 years benefited more from CEA than younger patients [12] (probably because elderly patients have a greater risk of ischemic stroke on medical treatment and a lower surgical risk), from the trial data it is impossible to say whether this applies to over 80-year-olds
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