Carotid Endarterectomy In Elderly Patients Research Articles

Amantadine Alleviates Postoperative Cognitive Dysfunction Possibly by Preserving Neurotrophic Factor Expression and Dendritic Arborization in the Hippocampus of Old Rodents.

ObjectivesAmantadine has been shown to attenuate postoperative learning and memory dysfunction in young adult rats. However, postoperative cognitive dysfunction often occurs in elderly patients. We aimed to determine whether amantadine attenuated postoperative learning and memory dysfunction and whether these effects were associated with improved dendritic arborization in old rodents.MethodsEighteen-month old male C57BL/6J mice or Fischer 344 rats were subjected to right carotid artery exposure (surgery) under isoflurane anesthesia. This age represents an early old stage in rodents. Carotid artery exposure was used to simulate commonly performed carotid endarterectomy in elderly patients. Amantadine was injected intraperitoneally at 25 μg/g once a day for 3 days with the first dose at 15 min before surgery. The animals were tested by Barnes maze and fear conditioning starting one week after the surgery. Hippocampus was harvested for Western blotting and Golgi staining.ResultsSurgery and anesthesia impaired the learning and memory in old mice and rats. Surgery reduced the expression of brain-derived neurotrophic factor (BDNF) and glial cell line-derived neurotrophic factor (GDNF), dendritic arborization and spine density in the hippocampus of old rats. These effects were attenuated by amantadine. The effects of amantadine were blocked by intracerebroventricular injection of anti-BDNF antibody or anti-GDNF antibody.ConclusionSurgery and anesthesia impaired learning, memory and dendritic arborization in old rodents that are age relevant to postoperative cognitive dysfunction. These effects may be attenuated by amantadine via preserving the expression of neurotrophic factors.

Near infrared spectroscopy monitoring during carotid endarterectomy in elderly patients

Materials and methods 193, consecutive patients, 101 males, mean age 72 years, underwent CEA in our Institution from September 2007 to December 2009. All operations were only performed by two surgeons and all patients were monitored with TCO during general anesthesia. TCO parameters were always registered in: base-line, anesthesia induction, carotid clamping and declamping, wake up and estubation. The relationship with TCO was described in terms of the decrease in percentage oxygenation. Standard endarterectomy was performed through a longitudinal arteriotomy. The majority of arteriotomies were sutured with a dacron patch. Primary suturing was done only when it was possible to use the eversion technique.

Early and long-term outcomes of carotid endarterectomy in the very elderly: An 18-year single-center study

To evaluate the perioperative (30-day) and long-term outcomes of carotid endarterectomy (CEA) in elderly patients with severe symptomatic and asymptomatic carotid disease. Although the efficacy of CEA in preventing stroke in selected patients has been clearly demonstrated, concern has been expressed about the role of CEA in people over 80 years old. An analysis was conducted on a prospectively compiled computerized database of all primary CEAs performed at our institution from 1990 to 2007. Descriptive demographic data, risk factors, surgical details, perioperative strokes and deaths, and other complications were recorded. All patients underwent postoperative duplex ultrasound scanning and clinical follow-up at one, six, and 12 months, and yearly thereafter. Survival analyses were performed using Kaplan-Meier life-tables. Long-term relative survival after CEA was assessed against age- and gender-matched controls. In all, 1769 CEAs were performed in 1562 patients, 193 of them (207 CEAs; group I) were > or = 80 years old and 1371 were younger (1562 CEAs; group II). All CEA procedures were performed with patients under deep general anesthesia with continuous perioperative EEG monitoring for selective shunting. No strokes or deaths occurred in group I, whereas there were 11 perioperative strokes and three deaths in group II (1%). A complete follow-up (median, 5.2 years) was obtained in 185 elderly patients: no late occlusions or restenoses were detected, while the seven-year freedom from stroke and death were 96.6% and 52.4%, respectively. The relative seven-year survival rate was 99.8%. CEA in elderly patients proved safe and effective, with an excellent long-term durability. The long-term relative survival after CEA in elderly patients was better than in an age-and gender-matched population, so the likelihood of living long enough to benefit from CEA is not jeopardized by being very elderly.

Carotid Endarterectomy as the Criterion Standard in High-Risk Elderly Patients

Carotid angioplasty and stenting (CAS) is now a viable alternative to carotid endarterectomy (CEA) in patients considered to be high-risk candidates for surgery, despite recent reports of increased adverse periprocedural outcomes in elderly patients. We sought to evaluate our single-institution experience and the 30-day perioperative outcomes of CEA in patients 75 years or older, who are traditionally considered high-risk surgical candidates and are recommended for CAS. Retrospective medical record review. Academic tertiary care center. All patients 75 years or older undergoing CEA during a 16-year period. Primary outcome of 30-day perioperative stroke, death, or myocardial infarction (MI) and a composite outcome of stroke, death, or MI. Secondary outcomes of all perioperative complications were exclusive of primary outcomes. One hundred seventeen CEAs were performed in 110 patients 75 years or older. Significant medical comorbidities were well represented among the group. Among the patients, 50.4% were symptomatic, 60.7% had greater than 90% carotid stenosis, and 44.4% had contralateral disease. Primary outcome for any stroke, death, or MI was 1.7%, 0.9%, or 3.4%, respectively, with a composite event rate of any stroke or death of 2.6%. One or more secondary outcomes were experienced by 26.5% of patients. Carotid endarterectomy in elderly patients with significant comorbidities, traditionally thought to be a high-risk undertaking, is a safe procedure with periprocedural risks of stroke, death, and MI equivalent to those of younger patients. In light of the increased stroke risk in elderly patients with CAS, CEA remains the criterion standard for prevention of stroke in this patient population.

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Carotid endarterectomy in elderly patients: low complication rate with overnight stay.

Elderly patients undergoing carotid endarterectomy (CEA) can have a low complication rate and a short hospital stay. In this case series, we compared CEA results from January 1, 1994, through December 31, 1998, in 2 different age groups: 71 to 80 years and 81 years and older. A private vascular surgery practice. We studied 271 patients who underwent 293 CEAs; 124 procedures were for patients in the 71- to 80-year-old age group, and 42 procedures were for patients aged 81 years and older. Classic CEA was performed on all patients. From 1994 through 1996, 179 operations were performed under general anesthesia with routine shunting. In 1997 and 1998, 114 operations were performed under locoregional anesthesia with selective shunting. Length of hospital stay and 30-day morbidity and mortality. The mortality rate for the entire series was 0.7% (2 of 293 patients). Major cardiac complications occurred in 3 patients (1.0%). Perioperative stroke occurred in 3 cases(1.0%); 2 strokes occurred in patients aged 71 to 80 years (2 [1.6%] of 124 patients), and 1 occurred in a patient aged 81 years or older (1 [2.4%] of 42 patients). Two additional patients developed reversible ischemic neurological deficits but were not in the elderly group (> or =81 years and older). The mean hospital stay was 1.5 days for patients aged 71 to 80 years and 1.2 days for patients aged 81 years and older. All outcome variables were statistically similar in both age groups. Octogenarians can undergo CEA with little morbidity and mortality and virtually an overnight hospital stay.

Carotid Endarterectomy in Elderly Patients—Invited Critique

Carotid Endarterectomy in Elderly Patients—Invited Critique

Risk, Causes and Prevention of Ischemic Stroke in Elderly Patients with Symptomatic Internal Carotid Artery Stenosis

91 Background. Atherosclerosis is an important cause of stroke in the elderly. Carotid endarterectomy (CE) benefits patients with 70–99% symptomatic internal carotid artery (ICA) stenosis, less for patients with 50–69% stenosis. The benefit of CE in elderly patients (≥75 years) requires evaluation. Methods. Elderly patients with symptomatic ICA stenosis were compared to those 65–74 years and <65 years in regards to baseline characteristics, risk of ipsilateral ischemic stroke at 2 years by degree of stenosis and treatment group and risk of ischemic stroke in the territory of an asymptomatic contralateral carotid artery. Results. The risk of ipsilateral ischemic stroke was highest in the medically-treated elderly regardless of the degree of stenosis. Among 659 patients with 70–99% stenosis, the absolute risk reduction (ARR) of ipsilateral ischemic stroke by CE was 28.9% for patients ≥75 years (N=71), 15.1% for 65–74 years (N=285) and 9.7% for <65 years (N=303). Among patients with 50–69% stenosis, the ARR was significant only in those ≥75 years (N=145) with an ARR of 17.3%. The perioperative risk of stroke and death at any degree of stenosis was less in the elderly: 5.1% for patients ≥75 years, 5.4% for 65–74 years and 7.8% for <65 years. The numbers of patients ≥75 years with 70–99% and 50–69% stenosis needed to treat (NNT) by CE to prevent one ipsilateral stroke within 2 years were 3 and 6, respectively. For 60–99% asymptomatic contralateral ICA stenosis, the 2 year risk of stroke was 7.8% in patients ≥75 years and 7.4% in those < 75 years. The risk of ischemic stroke at 5 years in the territory of a 60–99% asymptomatic ICA stenosis was higher in patients ≥75 years (24.8%) than in patients <75 years (14.9%). Conclusions. In the prevention of ipsilateral ischemic stroke, elderly patients with 50–99% symptomatic carotid stenosis benefited more from CE than younger patients. To achieve this benefit, patients must be carefully selected, excluding those with other life threatening illnesses.

Carotid endarterectomy in elderly patients: Meyer FB, Meissner I, Fode NC, Losasso TJ. Mayo Clin Proc 1991;78:464–469

Carotid endarterectomy in elderly patients: Meyer FB, Meissner I, Fode NC, Losasso TJ. Mayo Clin Proc 1991;78:464–469

Carotid Endarterectomy in Elderly Patients

Between 1971 and 1989, 749 carotid endarterectomies were performed at our institution for symptomatic carotid occlusive disease in patients older than 70 years of age. Of these procedures, 693 were done in patients 71 through 80 years of age, and 56 were done in patients between the ages of 81 and 90 years. The neurologic morbidity and perioperative mortality in the former group were 2.9% and 1.4%, respectively, whereas in the latter group the corresponding values were 5.4% and 0%, respectively. For the entire group, the neurologic morbidity was 3.1% and the mortality was 1.3%. Of the 23 new postoperative neurologic deficits, 19 (83%) occurred in high-risk patients with severe preoperative neurologic or medical risks, and 14 (61%) of these deficits were minor. In selected elderly patients with symptomatic hemodynamically significant carotid occlusive disease, endarterectomy seems to be a safe procedure that is associated with acceptably low perioperative morbidity and mortality.