National Utilization and Outcome of Carotid Artery Revascularization in Octogenarians

Abstract

The benefits of carotid endarterectomy (CEA) and carotid artery angioplasty and stenting (CAS) in octogenarians remain unclear. Octogenarians were excluded from seminal CEA trials. CAS may have increased complications in this patient cohort. The objective of this study was to examine the national utilization and outcome of CEA and CAS in octogenarians. The Nationwide Inpatient Sample (2004-2005) was utilized. ICD-9 codes were used to identify CEA and CAS cases. Outcomes included in-hospital stroke and death. Comparisons were performed between older and younger patients. Analysis was performed among octogenarians to identify whether improved outcomes were noted with either procedure. A total of 54,658 cases were analyzed; 10,826 were in octogenarians (19.8%). Octogenarians who underwent carotid procedures were more likely to be female (45.6% vs 41.5%, P < .001) and to die in the hospital (1.0% vs 0.6%, P < .001) than younger patients who underwent carotid procedures. There were no overall differences in the prevalence of preoperative symptoms (5.4% vs 5.3%), the use of CAS as opposed to CEA (6.0% vs 5.8%), or the overall rate of periprocedural stroke (1.1% vs 1.1%) between octogenarians and younger patients. However, asymptomatic octogenarians were more likely to undergo CAS (as opposed to CEA) than asymptomatic younger patients (10.1% vs 5.7%, P < .001). In separate analysis of octogenarians alone, it was noted that they had a significantly higher rate of periprocedural stroke with CAS than with CEA (2.2% vs 1.1%, P < .01). The increased rate of stroke with CAS as opposed to CEA was noted in both asymptomatic (1.9% vs 0.9%, P = .04) and symptomatic (5.2% vs 2.3%, P = .18) octogenarians. Nationally, octogenarians comprise nearly 20% of patients undergoing carotid revascularization procedures, despite concern regarding the benefits of these procedures in older patients, particularly when asymptomatic. In spite of additional specific concerns regarding the complication rate of CAS in patients older than 80 years of age, asymptomatic octogenarians underwent CAS as opposed to CEA significantly more frequently than younger patients. However, their periprocedural stroke rate overall was equally low when compared to younger patients. Furthermore, among octogenarians, the rate of periprocedural stroke was significantly higher with CAS than with CEA, and this remained a significant finding when asymptomatic cases were separately examined. CEA may be the treatment of choice for properly selected octogenarians, unless compelling reasons exist to perform CAS.