Is Age of 80 Years a Threshold for Carotid Revascularization?
Current Cardiology Reviews, 2011, 7, 15-2115
1573-403X/11 $58.00+.00 © 2011 Bentham Science Publishers Ltd.
Boudewijn L. Reichmann, Guus W. van Lammeren, Frans L. Moll and Gert J. de Borst*
Department of Vascular Surgery, University Medical Centre Utrecht; The Netherlands
Abstract: Background and purpose: Carotid Angioplasty and Stenting (CAS) has emerged as an alternative to Carotid
Endarterectomy (CEA) in treatment of carotid stenotic disease. With increasing life expectancy clinicians are more often
confronted with patients of higher age. Octogenarians were often excluded from randomized trials comparing CAS to
CEA because they were considered high-risk for revascularization. Conflicting results on the peri-procedural outcome of
carotid revascularization in these patients have been reported. In order to objectively evaluate whether age above 80 years
should be an upper limit for indicating carotid revascularization we systematically reviewed the currently available litera-
Methods: Literature was systematically reviewed between January 2000 and June 2010 using Pubmed and Embase, to
identify all relevant studies concerning CAS and CEA in octogenarians. Inclusion criteria were 1) reporting outcome on
either CEA or CAS; and 2) data subanalysis on treatment outcome by age. The 30-day Major Adverse Event (MAE) rate
(disabling stroke, myocardial infarction or death) was extracted as well as demographic features of included patients.
Results: After exclusion of 23 articles, 46 studies were included in this review, 18 involving CAS and 28 involving CEA.
A total of 2.963 CAS patients and 14.365 CEA patients with an age >80 years were reviewed. The MAE rate was 6.9%
(range 1.6 - 24.0%) following CAS and 4.2% (range 0 – 8.8%) following CEA.
A separate analysis in this review included the results of one major registry 140.376 patients) analyzing CEA in octoge-
narians only reporting on 30-day mortality and not on neurological or cardiac adverse events. When these data were in-
cluded the MAE following CEA is 2.4% (range 0 – 8.8%)
Conclusions: MAE rates after CEA in octogenarians are comparable with the results of large randomized trials in younger
patients. Higher complication rates are described for CAS in octogenarians. In general, age > 80 years is not an absolute
cut off point to exclude patients from carotid surgery. In our opinion, CEA should remain the golden standard in the
treatment of significant carotid artery stenoses, even in the very elderly.
Keywords: Carotid revascularization, angioplasty, stenting, octogenarians, demographic features, revascularization.
Carotid Angioplasty and Stenting (CAS) has emerged as
an alternative to Carotid Endarterectomy (CEA) for the
treatment of carotid artery stenoses in the prevention of
stroke 1. Recent results of large randomized trials have
shown that CAS however has a higher peri-procedural com-
plication rate compared to CEA [2-4]. The authors concluded
that CAS should only be considered in high-risk patients not
suitable for surgery and that CEA remains the gold standard
until long-term results of randomized trials can be reported.
The question remains which patients should be consid-
ered as high-risk patients. Previous neck surgery, prior neck
cancer with radiation therapy, clinical significant cardiopul-
monary disease or an age above 80 have been exclusion
criteria in many large carotid trials that were conducted to
evaluate the durability of CEA for the prevention of stroke
[5-9]. Age has also been identified as an independent predic-
tor of complications in carotid interventions [10-12]. Mean
life expectancy has steadily increased over time, and elderly
*Address correspondence to this author at the University Medical Center
Utrecht, Department of Vascular Surgery, G 04.129 PO Box 85500 3508
GA Utrecht, The Netherlands; Tel: 0031-88-7556965;
Fax: 0031-88-7551944; E-mail: G.J.deBorstemail@example.com
people have become the fastest growing population segment
in industrialized countries. Hence, elderly people are typi-
cally seen in everyday clinical practice and will become an
increasingly important group of patients in the future. “High-
risk” patients were often offered the endovascular alternative
to surgical treatment because CAS is considered to be a less
invasive revascularization option. Some authors state that
CAS can be performed safely in high-risk patients [13-15],
but subgroups often are too small to draw any conclusions on
the procedural risk of for example patients of higher age.
Octogenarians however, were excluded from most trials
evaluating CAS. To date, there has not been a randomized
trial comparing CAS with CEA in octogenarians.
In order to answer two specific questions; 1) is carotid
revascularization in octogenarians safe to perform; and 2) is
CAS compared to CEA a safer treatment option for octoge-
narians in terms of perioperative MAE; we systematically
reviewed current literature on carotid revascularization in
Literature was searched to identify all relevant studies on
carotid revascularization in octogenarians. The search was
restricted to papers published between January 2000 and
Current Cardiology Reviews, 2011, Vol. 7, No. 1 Reichmann et al.
June 2010. Studies were initially identified from the Med-
line/Pubmed database, EMBASE and the Cochrane database
using the search terms “carotid stenosis”, “carotid an-
gioplasty”, “carotid stenting”, “carotid revascularization”,
“carotid endarterectomy”, “octogenarians” and “(very) eld-
Studies were included if they reported on octogenarians
treated by CAS or CEA. Results of major adverse events
(MAE) (disabling stroke, myocardial infarction or death) had
to be described in order to be included. Studies however
were excluded if: 1) The age of the patient population was
<80 years, 2) review articles or letters did not describe rates
of major adverse events, 3) articles were written in non-
English language . The reference list of the included articles
was also screened for additional studies concerning our sub-
ject. Data on 30-day MAE rates as well demographic fea-
tures of the included patients were extracted from the articles
Sixty-nine studies were initially identified with our
search strategy (Fig. 1; flow chart). Of these 69 initial arti-
cles, 10 articles did not meet our inclusion criteria, 2 were
case reports, 4 articles were written in non-English languages
and 4 articles lacked description of Major Adverse Event
(MAE). Six articles were excluded because there was a lack
of demographic data on included patients and 7 articles de-
scribed carotid revascularization in a patient population with
an average age <80 years. After exclusion 46 articles met our
inclusion criteria (18 CAS and 28 CEA) [16-60].
Carotid Angioplasty and Stenting in Octogenarians
The combined amount of CAS procedures performed in
the included articles was 10.896. Of these procedures 2.837
were performed in octogenarians. Demographic features and
an outline of included articles are shown in Table 1. Forty-
nine percent of patients treated by CAS were symptomatic.
In two series, a significant higher complication rate was
observed in symptomatic octogenarians compared to asymp-
tomatic octogenarians [21, 24].
Other series included in this review did not analyze the
difference between symptomatic and asymptomatic octoge-
narians. An Embolic Protection Device (EPD) was used in
86% of the patients. Usman et al who conducted a meta-
analysis on carotid revascularization in octogenarians de-
scribe a review of 826 patients 19. They concluded that octo-
genarians undergoing CAS have a 3.46-times higher absolute
risk of stroke than those undergoing CEA, with no signifi-
cant difference in mortality and a trend toward a lower rate
of myocardial infarction. The rate of MAE (disabling stroke,
myocardial infarction or death) varied from 1,6 to 24%. The
total number of MAE was 206 which corresponds to a com-
bined MAE rate of 6,9% in the 2.837 included patients.
These MAE’s were mainly stroke related; myocardial infarc-
tion was relatively rare following CAS. Zahn et al reported
only non-fatal strokes and death and did not analyze cardiac
24. Their MAE rate of 5,5% is therefore
Fig. (1). Flow chart of search results.
Is Age of 80 Years a Threshold for Carotid Revascularization? Current Cardiology Reviews, 2011, Vol. 7, No. 1 17
peri-procedural MAE [25, 27, 31], and thus age over 80 was
an exclusion criterium in many carotid trials. This policy
however was not endorsed by the results of other authors in
this review. They did not observe significant increases in
complication rates of octogenarians compared to younger
The use of an EPD is essential in the prevention of peri-
procedural cerebrovascular events according to three authors,
because of the observed higher event rate compared to un-
protected CAS procedures [23, 24, 26].
An age > 80 years is as an independent risk factor for
Carotid Endarterectomy in Octogenarians
Much more data are available on CEA in octogenarians.
The included articles and their demographic features are
outlined in Table 2. The by far largest cohort was reported
by Lichtman et al. who analyzed data of all 140.376 patients
older than 80 years undergoing CEA in the United States
during a period of 6 years (1993-1999) . They collected
data on patients from their medical records. Their group
reported a 30-day mortality rate of 2,2% but did not specify
the cause of death nor did they report on cerebrovascular
complication rates. Ninety-three of the total included patients
in this review are coming from their patient population. If
this group is included the combined MAE rate would be
2,4%. This however considerably underestimates the exact
MAE rates because of the lack of figures about neurological
and cardiac complications.
When the study of Lichtman is not included, a patient
population of 60.060 containing 14.365 octogenarians re-
mains for analysis. In total 47% of the included patients
undergoing CEA were symptomatic. The MAE rates in the
included articles varied between 0-8,3%. The total number of
MAE was 606 on a total of 14.365 CEA’s in patients older
than 80. The combined MAE rate was 4.2%. Two authors
describe that especially symptomatic octogenarians are more
at risk for peri-procedural complications compared to asymp-
tomatic patients undergoing CEA [39, 59].
With the increasing life expectancy clinicians are more
often confronted with elderly patients affected by carotid
obstructive disease. It has been estimated that 30-40% of
strokes in octogenarians are secondary to stenotic or occlu-
sive disease of the carotid bifurcation . Carotid revascu-
larization in the elderly remains controversial and conflicting
Table 1. Carotid Angioplasty and Stenting (CAS) Study Collection and 30-day MAE Rates.
First author Year Total CAS Octogenarians, NMale Mean age Symptomatic EPD usedNr of MAE'sMAE (%)
Micari  2010 198 198 68% 83.2 39% 100% 5 2.5%
Grant  2010 418 418 63% 83.2 32% 79% 14 3.3%
Bacharach  2010 235 78 72% 83.5 20% 99% 7 9.0%
Usman*  2009 826 826 NR 82.2 65% 100% 84 9.9%
Linfante  2009 178 24 67% 82.4 71% 100% 2 8.4%
Cremonesi  2009 1.523 237 72% NR 24% 88% 5 2.1%
Jackson  2008 215 35 53% NR 41% 92% 4 11.4%
Henry  2008 930 121 72% 82.0 64% 95% 2 1.6%
Velez  2008 816 126 56% 82.9 40% 50% 3 2.7%
Zahn**  2007 2.878 321 65% 82.5 61% 68% 18 5.5%
Lam  2007 135 37 65% 85.0 100% 99% 4 10.8%
Villalobos  2006 75 75 55% 83.1 56% 54% 18 24.0%
Stanziale  2006 382 87 83% 83.0 18% 62% 8 9.2%
Setacci  2006 1.222 144 75% 82.0 65% 92% 5 3.5%
Longo  2005 158 29 74% 82.3 17% 89% 1 3.4%
Hobson  2004 749 99 64% NR 30% 100% 12 12.1%
Roubin  2001 604 66 67% NR 52% 100% 11 16.0%
Shawl  2000 170 42 59% NR 61% 0% 1 2.9%
Total 11.712 2.963 67% 82.9 49% 86% 203 6.9%
* Meta-analysis of CAS vs. CEA in octogenarians
** All non-fatal strokes and death
MAE: Major Adverse Events (disabling stroke, myocardial infarction or death)
18 Current Cardiology Reviews, 2011, Vol. 7, No. 1 Reichmann et al.
results on peri-procedural outcome have been reported. Two
studies however, have shown that, on average, 80% of octo-
genarians survive at least 4 years after endarterectomy and
that the vast majority is stroke free at 5 to 10 years follow-up
[58, 62]. Norman et al conclude that the likelihood of living
long enough to gain benefit from a carotid endarterectomy is
not jeopardized by being too old . Elderly patients with a
symptomatic carotid stenosis treated by best medical treat-
ment have the highest risk on future cerebrovascular events
. It might therefore be beneficial to offer any carotid
revascularization, whether surgical or endovascular, to octo-
genarians to decrease this relatively high risk of (recurrent)
Table 2. Carotid Endarterectomy (CEA) Study Collection and 30-day MAE Rates.
First author Year Total CEA Octogenarians, N Male Mean age, ySymptomatic Nr of MAE'sMAE (%)
Lichtman  2010 140.376 140.376 NR 83.0 NR 3.088 2.2%
Usman*  2009 7.017 7.017 NR 82.7 54% 316 4.5%
Halm  2009 9.308 2.198 NR NR NR 106 4.8%
Bremner  2008 195 105 62% 83.7 43% 6 5.7%
Ballotta  2006 1.260 112 62% 84.2 66% 1 0.9%
Teso  2005 14.679 2.379 54% NR 11% 100 4.2%
Pulli  2005 1.883 149 70% NR NR 1 0.6%
Miller  2005 2.217 360 NR 83.6 59% 15 4.2%
Lau  2005 286 33 100% 82.0 51% 3 8.0%
Grego  2005 1.733 125 66% NR 50% 1 0.8%
Durward  2005 1.800 26 NR 91.3 81% 0 0.0%
Varghese  2004 359 33 61% NR 76% 3 8.8%
Hingorani  2004 565 299 51% NR 43% 8 2.7%
Ballotta  2004 1.150 92 52% 83.7 66% 0 0.0%
Witz  2003 360 47 66% 82.0 51% 4 8.3%
Rockman  2003 698 161 52% NR 46% 4 2.5%
Pruner  2003 3.430 269 62% 82.9 83% 8 3.1%
Norman  2003 2.023 151 67% NR NR 4 2.6%
Salameh  2002 293 42 NR NR NR 2 4.8%
Ozsvath  2002 3.932 125 45% 83.0 50% 3 2.4%
Metz  2002 32 32 50% 82.0 100% 1 3.2%
Cartier  2002 475 65 51% 82.6 76% 2 2.8%
Saha  2002 101 101 NR 86.5 71% 3 3.0%
Ommer  2001 2.262 70 63% 82.9 74% 3 4.2%
Lepore  2001 366 42 63% 82.8 40% 1 2.4%
Ting  2000 656 57 58% 82.0 86% 4 6.8%
Schneider  2000 582 88 61% 83.2 75% 1 1.1%
Maxwell  2000 2.398 187 47% 83.0 65% 8 4.1%
Total incl. Lichtman et al 200.436 154.741 NR 83.5 47% 3.695 2.4%
Total excl. Lichtman et al 60.060 14.365 NR 83.5 NR 606 4.2%
* 30-day Mortality rates, stroke not analysed
** Meta-analysis of CAS vs. CEA in octogenarians
MAE: Major Adverse Events (disabling stroke, myocardial infarction or death)
Is Age of 80 Years a Threshold for Carotid Revascularization? Current Cardiology Reviews, 2011, Vol. 7, No. 1 19
narians have an increased risk of major adverse events dur-
ing CAS compared to CEA. A recent meta-analysis concern-
ing carotid revascularization in octogenarians showed that
the peri-procedural all-stroke rate was significantly higher
during CAS . The absolute risk on stroke was 3.46-times
higher compared to patients undergoing CEA. There was
also a trend towards higher mortality and myocardial infarc-
tion rates but these results did not reach statistical signifi-
cance. Several other authors like the CREST investigators
endorse the conclusion of this meta-analysis. After interim
analysis of the results of the lead-in phase of the CREST trial
the inclusion of octogenarians was stopped. Octogenarians
showed a 30-day stroke/death rate of 12.1% compared to
3.2% in younger patients .
Other authors invalidate inferiority of CAS in octoge-
narians and showed excellent results in their patient popula-
tions [16, 18, 20, 28]. A recent meta-analysis by Bonati et al.
containing the pooled data of three recent large randomized
trials confirmed the significant higher complication rates
following CAS in patients > 75 years 
The explanation for this increase in major adverse events
after CAS compared to CEA is poorly defined. Anatomic
characteristics might play an important role in the occurrence
of major adverse events. Octogenarians have an increased
incidence of complex anatomic risk factors compared to
younger patients [25, 65]. Lam et al have described several
of these characteristics. They concluded that octogenarians
have an increased incidence of unfavorable arch elongation,
arch calcification, common carotid or innominate artery
origin stenosis, common carotid artery tortuosity, and inter-
nal carotid artery tortuosity. Increased arch calcium content
and type II aortic arches may be markers of increased poten-
tial for embolization during endovascular manipulation that
transverses the aortic arch . The rate of embolic events
during CAS is considered to decrease when an embolic pro-
tection device (EPD) is used but preliminary manipulation of
interventional devices through a calcified aortic arch might
already have contributed to cerebral lesions, prior to EPD
placement. The discussion on the standard use of CPD not
closed; also in the light of recent findings that new cerebral
infarctions were higher in CAS than in CEA, especially in
CPD assisted CAS . Kastrup et al also described the
correlation between the incidence of new lesions on diffu-
sion–weighted imaging and aortic arch calcification in the
Another explanation might be found in plaque character-
istics at the target site. There are no data available in the
current literature reporting on specific carotid plaque charac-
teristics in octogenarians, but plaque stability has been re-
ported to decrease with age . It might be conceivable that
the underlying plaque composition in octogenarians is more
unstable and rupture prone, compared to carotid plaques in
younger patients, which might contribute to the increased
risk for thrombo-embolic events during CAS, due to plaque
disruption initiated by endovascular devices and stents. Our
study group is currently conducting a study concerning
plaque stability in octogenarians compared to younger pa-
tients, but results have to be awaited.
The result of this systematic review shows that octoge-
EPD might prevent some events but the embolization can
occur during each step of the procedure. A lot of these mi-
cro-emboli occur subclinically but some factors could pro-
voke subclinical events and lesions to become clinical. One
of these factors is cerebral reserve but data concerning the
effect of cerebral reserve on outcome of carotid revasculari-
zation is poorly defined in octogenarians. Chaer et al studied
cerebral reserve and saw that an age >/=70 is associated with
poor cerebral reserve in patients with significant carotid
stenosis as measured by Cerebral Blood Flow response to an
acetazolamide challenge . This poor reserve might make
older patients more sensitive to micro-emboli and therefore
explain the higher risk of stroke during CAS compared to
Interventionalists often attribute higher rates of major
adverse events during CAS in large randomized trials to the
fact that less experienced interventionalists are compared to
experienced surgeons. Experienced interventionalists are
more likely to recognize treacherous anatomy and make
adjustments to minimize procedural risks than less experi-
enced operators. Patient selection and a well considered
choice for an either surgical or endovascular approach re-
mains a key factor in carotid revascularization. Some authors
therefore believe that when appropriate patient selection and
evaluation of their preoperative risk factors is performed
equal peri-procedural results can be achieved in CAS and
CEA in high risk patients 71 So far, however, the data derived
in this review concluded otherwise.
Whether or not a patient is symptomatic could attribute to
the risk of major adverse events. A carotid artery stent regis-
try noted a significant difference in stroke rates in sympto-
matic octogenarians of 7.1% versus 3.9% in younger symp-
tomatic patients. This relevant difference was not found in
asymptomatic patients (3.4% vs. 2.6%). Other authors, in-
cluding the CREST investigators, did not find an increased
peri-procedural complication rate between symptomatic and
asymptomatic octogenarians 
The data obtained in this review show a 30-day MAE rate
of 4.2% following CEA in octogenarians. This MAE rates
are consistent with complication rates of recent large ran-
domized trials in non-octogenarians [2-4]. It seems a consis-
tent finding that CEA can be safely performed in the very
elderly with equal complication rates compared to a younger
This review is limited by the age cut-off point. On pur-
pose, we focused on octogenarians (age > 80 years) whereas
some authors use an age > 75 years to define elderly in their
studies. Our main focus was on octogenarians and therefore
we had to discard and exclude 7 articles from our review.
Embolization is not uncommon during CAS. The use of
Age is not a criterion to withhold patients from surgery.
CEA in both symptomatic and asymptomatic octogenarians
can be performed with comparable and acceptable peri-
procedural complication rates as in younger patients. Higher
complication rates in patients older than 80 years occur with
CAS. Therefore, CEA must remain the gold standard in the
20 Current Cardiology Reviews, 2011, Vol. 7, No. 1 Reichmann et al.
treatment of carotid occlusive disease, also in patients above
the age of 80.
 Investigators C. Endovascular versus surgical treatment in patients
with carotid stenosis in the Carotid and Vertebral Artery
Transluminal Angioplasty Study (CAVATAS): a randomised trial.
Lancet 2001; 357(9270): 1729-37.
Carotid artery stenting compared with endarterectomy in patients
with symptomatic carotid stenosis (International Carotid Stenting
Study): an interim analysis of a randomised controlled trial. Lancet
Ringleb PA, Allenberg J, Bruckmann H, et al. 30 day results from
the SPACE trial of stent-protected angioplasty versus carotid
endarterectomy in symptomatic patients: a randomised non-
inferiority trial. Lancet 2006; 368(9543): 1239-47.
Mas JL, Chatellier G, Beyssen B, et al. Endarterectomy versus
stenting in patients with symptomatic severe carotid stenosis. N
Engl J Med 2006; 355(16): 1660-71.
Collaborators NASCET. Beneficial
endarterectomy in symptomatic patients with high-grade carotid
stenosis. North American Symptomatic Carotid Endarterectomy
Trial Collaborators. N Engl J Med 1991; 325(7): 445-53.
MRC European Carotid Surgery Trial: interim results for
symptomatic patients with severe (70-99%) or with mild (0-29%)
carotid stenosis. European Carotid Surgery Trialists' Collaborative
Group. Lancet 1991; 337(8752): 1235-43.
ACAS. Endarterectomy for asymptomatic carotid artery stenosis.
Executive Committee for
Atherosclerosis Study. JAMA 1995; 273(18): 1421-8.
Mayberg MR, Wilson SE, Yatsu F, Weiss DG, Messina L, Hershey
LA, et al. Carotid endarterectomy and prevention of cerebral
ischemia in symptomatic carotid stenosis. Veterans Affairs
Cooperative Studies Program 309 Trialist Group. JAMA 1991;
Hobson RW, 2nd, Weiss DG, Fields WS, Goldstone J, Moore WS,
Towne JB, et al. Efficacy of carotid endarterectomy for
asymptomatic carotid stenosis. The Veterans Affairs Cooperative
Study Group. N Engl J Med. 1993; 328(4): 221-7.
Fisher ES, Malenka DJ, Solomon NA, Bubolz TA, Whaley FS,
Wennberg JE. Risk of carotid endarterectomy in the elderly. Am J
Public Health 1989; 79(12): 1617-20.
Goldstein LB, Samsa GP, Matchar DB, Oddone EZ. Multicenter
review of preoperative risk factors for endarterectomy for
asymptomatic carotid artery stenosis. Stroke 1998; 29(4): 750-3.
McCrory DC, Goldstein LB, Samsa GP, Oddone EZ, Landsman
PB, Moore WS, et al. Predicting complications of carotid
endarterectomy. Stroke 1993; 24(9): 1285-91.
Gurm HS, Yadav JS, Fayad P, et al. Long-term results of carotid
stenting versus endarterectomy in high-risk patients. N Engl J Med.
2008; 358(15): 1572-9.
Gray WA, Hopkins LN, Yadav S, et al. Protected carotid stenting
in high-surgical-risk patients: the ARCHeR results. J Vasc Surg
2006; 44(2): 258-68.
Linfante I, Hirsch JA, Selim M, Schlaug G, Caplan LR, Reddy AS.
Safety of latest-generation self-expanding stents in patients with
NASCET-ineligible severe symptomatic extracranial internal
carotid artery stenosis. Arch Neurol 2004; 61(1): 39-43.
Micari A, Stabile E, Cremonesi A, et al. Carotid artery stenting in
octogenarians using a proximal endovascular occlusion cerebral
protection device: a multicenter registry. Catheter Cardiovasc
Interv 2010; 76(1): 9-15.
Grant A, White C, Ansel G, Bacharach M, Metzger C, Velez C.
Safety and efficacy of carotid stenting in the very elderly. Catheter
Cardiovasc Interv 2010; 75(5): 651-5.
Bacharach JM, Slovut DP, Ricotta J, Sullivan TM. Octogenarians
are not at increased risk for periprocedural stroke following carotid
artery stenting. Ann Vasc Surg 2010; 24(2): 153-9.
Usman AA, Tang GL, Eskandari MK. Metaanalysis of procedural
stroke and death among octogenarians: carotid stenting versus
carotid endarterectomy. J Am Coll Surg 2009; 208(6): 1124-31.
Linfante I, Andreone V, Akkawi N, Wakhloo AK. Internal carotid
artery stenting in patients over 80 years of age: single-center
effect of carotid
the Asymptomatic Carotid
experience and review of the literature. J Neuroimaging 2009;
Cremonesi A, Gieowarsingh S, Spagnolo B, et al. Safety, efficacy
and long-term durability of endovascular therapy for carotid artery
disease: the tailored-Carotid Artery Stenting Experience of a single
high-volume centre (tailored-CASE Registry). EuroIntervention
2009; 5(5): 589-98.
Jackson BM, English SJ, Fairman RM, Karmacharya J, Carpenter
JP, Woo EY. Carotid artery stenting: identification of risk factors
for poor outcomes. J Vasc Surg 2008; 48(1): 74-9.
Henry M, Henry I, Polydorou A, Hugel M. Carotid angioplasty and
stenting in octogenarians: is it safe? Catheter Cardiovasc Inter.
2008; 72(3): 309-17.
Zahn R, Ischinger T, Hochadel M, et al. Carotid artery stenting in
octogenarians: results from the ALKK Carotid Artery Stent (CAS)
Registry. Eur Heart J 2007; 28(3): 370-5.
Lam RC, Lin SC, DeRubertis B, Hynecek R, Kent KC, Faries PL.
The impact of increasing age on anatomic factors affecting carotid
angioplasty and stenting. J Vasc Surg 2007; 45(5): 875-80.
Villalobos HJ, Harrigan MR, Lau T, et al. Advancements in carotid
stenting leading to reductions in perioperative morbidity among
patients 80 years and older. Neurosurgery 2006; 58(2): 233-40;
Stanziale SF, Marone LK, Boules TN, et al. Carotid artery stenting
in octogenarians is associated with increased adverse outcomes. J
Vasc Surg 2006; 43(2): 297-304.
Setacci C, de Donato G, Chisci E, et al. Is carotid artery stenting in
octogenarians really dangerous? J Endovasc Ther 2006; 13(3): 302-
Longo GM, Kibbe MR, Eskandari MK. Carotid artery stenting in
octogenarians: is it too risky? Ann Vasc Surg 2005; 19(6): 812-6.
Hobson RW, 2nd, Howard VJ, Roubin GS, et al. Carotid artery
stenting is associated with
octogenarians: 30-day stroke and death rates in the CREST lead-in
phase. J Vasc Surg 2004; 40(6): 1106-11.
Roubin GS, New G, Iyer SS, et al. Immediate and late clinical
outcomes of carotid artery stenting in patients with symptomatic
and asymptomatic carotid artery stenosis: a 5-year prospective
analysis. Circulation 2001; 103(4): 532-7.
Shawl F, Kadro W, Domanski MJ, et al. Safety and efficacy of
elective carotid artery stenting in high-risk patients. J Am Coll
Cardiol 2000; 35(7): 1721-8.
Lichtman JH, Jones SB, Wang Y, et al. Postendarterectomy
mortality in octogenarians and nonagenarians in the USA from
1993 to 1999. Cerebrovasc Dis 2010; 29(2): 154-61.
Halm EA, Tuhrim S, Wang JJ, Rockman C, Riles TS, Chassin MR.
Risk factors for perioperative death and stroke after carotid
endarterectomy: results of the new york carotid artery surgery
study. Stroke 2009; 40(1): 221-9.
Bremner AK, Katz SG. Are octogenarians at high risk for carotid
endarterectomy? J Am Coll Surg 2008; 207(4): 549-53.
Ballotta E, Da Giau G, Militello C, et al. High-grade symptomatic
and asymptomatic carotid stenosis in the very elderly. A challenge
for proponents of carotid angioplasty and stenting. BMC
Cardiovasc Disord 2006; 6: 12.
Teso D, Edwards RE, Frattini JC, Dudrick SJ, Dardik A. Safety of
carotid endarterectomy in 2,443 elderly patients: lessons from
nonagenarians--are we pushing the limit? J Am Coll Surg 2005;
Pulli R, Dorigo W, Barbanti E, et al. Does the high-risk patient for
carotid endarterectomy really exist? Am J Surg 2005; 189(6): 714-
Miller MT, Comerota AJ, Tzilinis A, Daoud Y, Hammerling J.
Carotid endarterectomy in octogenarians: does increased age
indicate "high risk?". J Vasc Surg 2005; 41(2): 231-7.
Lau D, Granke K, Olabisi R, Basson MD, Vouyouka A. Carotid
endarterectomy in octogenarian veterans: does age affect outcome?
A single-center experience. Am J Surg 2005; 190(5): 795-9.
Grego F, Lepidi S, Antonello M, et al. Is carotid endarterectomy in
octogenarians more dangerous than in younger patients? J
Cardiovasc Surg (Torino) 2005; 46(5): 477-83.
Durward QJ, Ragnarsson TS, Reeder RF, Case JL, Hughes CA.
Carotid endarterectomy in nonagenarians. Arch Surg 2005; 140(7):
625-8; discussion 8.
Varghese R, Norman P. Carotid endarterectomy in octogenarians.
ANZ J Surg 2004; 74(4): 215-7.
increased complications in
Is Age of 80 Years a Threshold for Carotid Revascularization? Current Cardiology Reviews, 2011, Vol. 7, No. 1 21 Download full-text
 Hingorani A, Ascher E, Schutzer R, et al. Carotid endarterectomy
in octogenarians and nonagenarians : is it worth the effort? Acta
Chir Belg 2004; 104(4): 384-7.
Ballotta E, Renon L, Da Giau G, Barbon B, Terranova O,
Baracchini C. Octogenarians with contralateral carotid artery
occlusion: a cohort at higher risk for carotid endarterectomy? J
Vasc Surg 2004; 39(5): 1003-8.
Witz M, Witz S, Shnaker A, Lehmann JM. Carotid surgery in the
octogenarians. Should patients' age be a consideration in carotid
artery endarterectomy? Age Ageing 2003; 32(4): 462-3.
Rockman CB, Jacobowitz GR, Adelman MA, et al. The benefits of
carotid endarterectomy in the octogenarian: a challenge to the
results of carotid angioplasty and stenting. Ann Vasc Surg 2003;
Pruner G, Castellano R, Jannello Am AM, et al. Carotid
endarterectomy in the octogenarian: outcomes of 345 procedures
performed from 1995-2000. Cardiovasc Surg 2003; 11(2): 105-12.
Norman PE, Semmens JB, Laurvick CL, Lawrence-Brown M.
Long-term relative survival in elderly patients after carotid
endarterectomy: a population-based study. Stroke 2003; 34(7): e95-
Salameh JR, Myers JL, Mukherjee D. Carotid endarterectomy in
elderly patients: low complication rate with overnight stay. Arch
Surg 2002; 137(11): 1284-7; discussion 8.
Saha SP, Rogers AG, Earle GF. Carotid endarterectomy in
octagenarians and nonagenarians in a community hospital: An
outcome analysis. Int J Angiol 2002; 11: 38-40.
Ozsvath KJ, Darling RC, Tabatabai L, et al. Carotid
endarterectomy in the elderly: does gender effect outcome?
Cardiovasc Surg 2002; 10(6): 534-7.
Metz R, Teijink JA, van de Pavoordt HD, et al. Carotid
endarterectomy in octogenarians with symptomatic high-grade
internal carotid artery stenosis: long-term clinical and duplex
follow-up. Vasc Endovascular Surg 2002; 36(6): 409-14.
Cartier B. Carotid surgery in octogenarians: why not? Ann Vasc
Surg 2002; 16(6): 751-5.
Ommer A, Pillny M, Grabitz K, Sandmann W. Reconstructive
surgery for carotid artery occlusive disease in the elderly--a high
risk operation? Cardiovasc Surg 2001; 9(6): 552-8.
Lepore MR, Jr., Sternbergh WC, 3rd, Salartash K, Tonnessen B,
Money SR. Influence of NASCET/ACAS trial eligibility on
outcome after carotid endarterectomy. J Vasc Surg.2001; 34(4):
Ting AC, Taylor DC, Salvian AJ, Chen JC, Strandberg S, Hsiang
YN. Carotid endarterectomy in octogenerians. Cardiovasc Surg
2000; 8(6): 441-5.
 Schneider JR, Droste JS, Schindler N, Golan JF. Carotid
endarterectomy in octogenarians: comparison with patient
characteristics and outcomes in younger patients. J Vasc Surg
2000; 31(5): 927-35.
Maxwell JG, Taylor AJ, Maxwell BG, Brinker CC, Covington DL,
Tinsley E, Jr. Carotid endarterectomy in the community hospital in
patients age 80 and older. Ann Surg 2000; 231(6): 781-8.
Velez CA, White CJ, Reilly JP, et al. Carotid artery stent
placement is safe in the very elderly (> or =80 years). Catheter
Cardiovasc Interv 2008; 72(3): 303-8.
Gelabert HA, Moore WS. Carotid endarterectomy: current status.
Curr Probl Surg 1991; 28(3): 181-262.
Perler BA, Williams GM. Carotid endarterectomy in the very
elderly: is it worthwhile? Surgery 1994; 116(3): 479-83.
Rothwell PM, Eliasziw M, Gutnikov SA, Warlow CP, Barnett HJ.
Endarterectomy for symptomatic carotid stenosis in relation to
clinical subgroups and timing of surgery. Lancet 2004; 363(9413):
Bonati LH, Dobson J, Algra A, et al. Short-term outcome after
stenting versus endarterectomy for symptomatic carotid stenosis: a
preplanned meta-analysis of individual patient data. Lancet 2010;
Lin SC, Trocciola SM, Rhee J, et al. Analysis of anatomic factors
and age in patients undergoing carotid angioplasty and stenting.
Ann Vasc Surg 2005; 19(6): 798-804.
Bazan HA, Pradhan S, Mojibian H, Kyriakides T, Dardik A.
Increased aortic arch calcification in patients older than 75 years:
implications for carotid artery stenting in elderly patients. J Vasc
Surg 2007; 46(5): 841-5.
Bonati LH, Jongen LM, Haller S, et al. New ischaemic brain
lesions on MRI after stenting or endarterectomy for symptomatic
carotid stenosis: a substudy of the International Carotid Stenting
Study (ICSS). Lancet Neurol 2010; 9(4): 353-62.
Kastrup A, Groschel K, Schnaudigel S, Nagele T, Schmidt F,
Ernemann U. Target lesion ulceration and arch calcification are
associated with increased incidence of carotid stenting-associated
ischemic lesions in octogenarians. J Vasc Surg 2008; 47(1): 88-95.
van Oostrom O, Velema E, Schoneveld AH, et al. Age-related
changes in plaque composition: a study in patients suffering from
carotid artery stenosis. Cardiovasc Pathol 2005; 14(3): 126-34.
Chaer RA, Shen J, Rao A, Cho JS, Abu Hamad G, Makaroun MS.
Cerebral reserve is decreased in elderly patients with carotid
stenosis. J Vasc Surg 2010; 52(3): 569-74.
Sadek M, Hynecek RL, Sambol EB, Ur-Rehman H, Kent KC,
Faries PL. Carotid angioplasty and stenting, success relies on
appropriate patient selection. J Vasc Surg 2008; 47(5): 946-51.
Received: October 16, 2010 Revised: October 16, 2010 Accepted: January 7, 2011