Is age of 80 years a threshold for carotid revascularization?

Department of Vascular Surgery, University Medical Centre Utrecht; The Netherlands.
Current Cardiology Reviews 02/2011; 7(1):15-21. DOI: 10.2174/157340311795677716
Source: PubMed

ABSTRACT 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 literature.
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.
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 octogenarians only reporting on 30-day mortality and not on neurological or cardiac adverse events. When these data were included the MAE following CEA is 2.4% (range 0 - 8.8%)
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.

  • [Show abstract] [Hide abstract]
    ABSTRACT: Elderly patients are a rapidly expanding segment of the population. Recent studies suggest that octogenarians have mortality and morbidity after carotid endarterectomy (CEA) similar to that in their younger cohort. Outcomes of CEA performed in nonagenarians have not been commonly reported; this study seeks to determine the safety of CEA in nonagenarians in general practice. All patients in nonfederal Connecticut hospitals undergoing CEA between 1990 and 2002 were identified using the state discharge database (Chime Inc; ). A total of 14,679 procedures were performed during the 12 study years. Sixty-four patients were nonagenarians (0.4%). Perioperative mortality was higher among nonagenarians (3.1%) compared with younger patients, including the 2,379 octogenarians (0.6%; p = 0.008, chi-square; odds ratio = 9.1, p = 0.006). No statistically significant difference was noted in perioperative stroke rates between nonagenarians (3.1%) and octogenarians (1.2%; p = 0.35, chi-square; odds ratio 2.3, p = 0.28). Nonagenarians had longer hospital lengths of stay (7.3 days, p < 0.0001), intensive care unit lengths of stay (1.2 days, p = 0.0013), and greater hospital charges ($17,967 +/- $1,907, p < 0.0001) than younger patients. Nonagenarians underwent operative procedures more frequently in an emergent setting (22%) compared with octogenarians (11%, p < 0.001) and had a greater percentage of symptomatic presentations (stroke: 14% versus 11%, p = 0.04; transient ischemic attack: 8% versus 5%, p = 0.04, respectively). All perioperative deaths and strokes occurred in symptomatic nonagenarians (15% versus 0%, p = 0.038; 15% versus 0%, p = 0.038; respectively). Carotid endarterectomy is performed in nonagenarians, as a group, with greater rates of perioperative mortality and morbidity than in younger patients, including octogenarians. But nonagenarians have a greater rate of symptomatic and emergent presentations than younger patients, which may account for their increased mortality, morbidity, length of stay, and incurred charges. Asymptomatic nonagenarians have similar outcomes after carotid endarterectomy compared with younger patients, including octogenarians, with low rates of mortality and morbidity.
    Journal of the American College of Surgeons 06/2005; 200(5):734-41. · 4.50 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The latest studies have clearly demonstrated the efficacy of carotid endarterectomy. However, most of these studies excluded patients over the age of 80. Some authors question the efficacy of and indication for endarterectomy in octogenarians. We therefore compared our results for endarterectomies on patients aged under and over 80. The author reviewed 475 carotid endarterectomies that he himself performed between July 1, 1990 and February 28, 2001; 72 of these procedures were carried out on 65 patients (15%) aged 80 and over. Both perioperative neurological events and mortality were studied. The outcome of carotid endarterectomy in both patient population groups was comparable; more than 70% of octogenarians were still alive 4 years later the same indications for carotid endarterectomy should therefore be applied to octogenarians.
    Annals of Vascular Surgery 12/2002; 16(6):751-5. · 0.99 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: To evaluate (1) whether carotid artery stenting (CAS) performed in octogenarians increases the procedure-related risk and (2) the incidence of complex anatomy of the aortic arch and supra-aortic vessels in patients >80 years old, which can increase the technical difficulty of CAS. Between December 2000 and September 2005, 1053 patients (903 men; mean age 72+/-2.2 years, range 46-90) underwent 1222 CAS procedures in 2 centers for de novo (n=1192) and restenotic (n=30) lesions (139 staged bilateral procedures). Indications for treatment were the presence of a symptomatic carotid artery stenosis >/=70% (n=798, 65.3%) or an asymptomatic stenosis of at least 80%. The patients were separated into 2 age categories: under 80 (n=1078 procedures, 88.2%) and 80 or older (n=144 procedures, 11.8%) for this analysis. Data analysis included death and stroke rate at discharge and at 30 days. Anatomical characteristics evaluated were aortic arch elongation, arch and supra-aortic vessel calcification and tortuosity, anatomical tortuosity of the lesion, and carotid plaque composition. Three lesions in octogenarians could not be treated because of failure to access the vessel in 1 case and extremely tortuous arteries in 2. The overall death and stroke rate at 30 days was 2.12% in the older group (2 fatal strokes, 1 minor stroke) and 1.11% in the younger group (3 deaths, 3 major strokes, 6 minor strokes); the difference was not statistically significant (p=0.40). Significantly higher frequencies of tortuosity and calcification of the arch and supra-aortic vessels and of type III aortic arch were observed in the older group (p<0.001). In our experience, CAS has proven to be safe and effective in elderly patients. Different age-related anatomical features can represent an adjunctive technical challenge, but these difficulties can be successfully managed without increased perioperative risk if CAS is performed in high-volume centers by highly skilled operators.
    Journal of Endovascular Therapy 06/2006; 13(3):302-9. · 2.70 Impact Factor

Full-text (2 Sources)

Available from
May 20, 2014