Carotid endarterectomy in the elderly

Safety of Carotid Endarterectomy for Symptomatic Stenosis by Age: Meta-Analysis With Individual Patient Data

BACKGROUND

There is uncertainty whether elderly patients with symptomatic carotid stenosis have higher rates of adverse events following carotid endarterectomy. In trials, recurrent stroke risk on medical therapy alone increased with age, whereas operative stroke risk was not related. Few octogenarians were included in trials and there has been no systematic analysis of all study types. We aimed to evaluate the safety of carotid endarterectomy in symptomatic elderly patients, particularly in octogenarians.

METHODS

We did a systematic review and meta-analysis of studies (from January 1, 1980 through March 1, 2022) reporting post carotid endarterectomy risk of stroke, myocardial infarction, and death in patients with symptomatic carotid stenosis. We included observational studies and interventional arms of randomized trials if the outcome rates (or the raw data to calculate these) were provided. Individual patient data from 4 prospective cohorts enabled multivariate analysis.

RESULTS

Of 47 studies (107 587 patients), risk of perioperative stroke was 2.04% (1.94-2.14) in octogenarians (390 strokes/19 101 patients) and 1.85% (1.75-1.95) in nonoctogenarians (1395/75 537); P=0.046. Perioperative death was 1.09% (0.94-1.25) in octogenarians (203/18 702) and 0.53% (0.48-0.59) in nonoctogenarians (392/73 327); P<0.001. Per 5-year age increment, a linear increase in perioperative stroke, myocardial infarction, and death were observed; P=0.04 to 0.002. However, during the last 3 decades, perioperative stroke±death has declined significantly in octogenarians (7.78% [5.58-10.55] before year 2000 to 2.80% [2.56-3.04] after 2010); P<0.001. In Individual patient data multivariate-analysis (5111 patients), age ≥85 years was independently associated with perioperative stroke (P<0.001) and death (P=0.005). Yet, survival was similar for octogenarians versus nonoctogenarians at 1-year (95.0% [93.2-96.5] versus 97.5% [96.4-98.6]; P=0.08), as was 5-year stroke risk (11.93% [9.98-14.16]) versus 12.78% [11.65-13.61]; P=0.24).

CONCLUSIONS

We found a modest increase in perioperative risk with age in symptomatic patients undergoing carotid endarterectomy. As stroke risk increases with age when on medical therapy alone, our findings support selective urgent intervention in symptomatic elderly patients.

Low carotid stump pressure as a predictor for ischemic symptoms and as a marker for compromised cerebral reserve in octogenarians undergoing carotid endarterectomy

BACKGROUND

Carotid artery occlusive disease can cause stroke by embolization, thrombosis, and hypoperfusion. The majority of strokes secondary to cervical carotid atherosclerosis are believed to be of embolic etiology. However, cerebral hypoperfusion could be an important factor in perioperative stroke. We retrospectively reviewed the stump pressure (SP) of carotid endarterectomy (CEA) of patients at Pennsylvania Hospital to identify whether physiologic perfusion differences account for differences in perioperative stroke rates, particularly in octogenarians.

METHODS

We conducted a retrospective review of our prospectively maintained database for CEA performed between 1992 and 2015. SP was measured and recorded for 1190 patients. A low SP was defined as systolic pressure <50 mm Hg. Shunts were used only for patients under general anesthesia with SP <50 mm Hg, for awake patients with neurologic changes with carotid clamping, and in some patients with recent stroke.

RESULTS

Symptomatic patients were more likely to have SP <50 mm Hg compared with asymptomatic patients (35.6% vs 26.2%; P = .0015). Patients having SP <50 mm Hg had a higher postoperative stroke rate compared with patients with SP >50 mm Hg (2.9% vs 0.9%; P = .0174). Octogenarians were more likely to have a lower SP compared with patients younger than 80 years (35.7% vs 27.7%; P = .0328). Symptomatic patients with low SP were at highest risk for perioperative stroke (6.4% vs 1.2%; P = .001) compared with patients without these factors.

CONCLUSIONS

SP is a marker for decreased cerebrovascular reserve and along with symptomatic status identifies those at highest risk for periprocedural stroke with CEA. Whereas patients older than 80 years may benefit from carotid intervention, they are likely to be at somewhat elevated stroke risk because of higher prevalence of low SP, and shunting does not eliminate this risk.

Influence of Age upon Complications of Carotid Artery Stenting

Purpose:

To examine the impact of age upon the development of neurological and major systemic complications during or after carotid artery stenting.

Methods:

We reviewed the complications that occurred in patients undergoing elective carotid stent implantation between September 1994 and August 1996. The study population was then divided into 3 groups according to age: ≥ 80 (group A), 75 to 79 (group B), and ≤ 74 (group C) years. The rates of death, major and minor stroke, and myocardial infarction were compared among the groups, as well as with the rates reported by the major carotid endarterectomy (CEA) trials.

Results:

During the study period, 182 patients (216 vessels) were treated with carotid stenting. There were 19 (10.4%) complications: 1 (0.5%) death, 2 (1.1%) major strokes, 15 (8.2%) minor strokes, and 1 (0.5%) myocardial infarction. Neurological complications were clearly related to increased age with rates of 25.0% in group A versus 8.6% in group C (p = 0.042). The overall per patient rate of death or major stroke was 1.6% (1.4% per vessel).

Conclusions:

Increasing age has a negative impact on the rate of complications in carotid stent patients. However, the majority of those complications are minor. The relative roles of medical therapy, stenting, and CEA in patients > 80 years of age must await the results of randomized trials.

[Mortality and morbidity of consecutive surgical carotid revascularisations in octogenarians]

AIM OF THE STUDY

Retrospective evaluation of the immediate and mid term mortality and morbidity of carotid surgical revascularisations in a population of octogenarians with severe carotid artery stenosis.

MATERIAL AND METHOD

Retrospective study of all patients 80 years old and more, consecutively operated for an internal carotid artery stenosis, from January 1991 to December 2003, in the Unit of Vascular Surgery of the Civil Hospices of Strasbourg. We analyzed the perioperative death and stroke rates at 30 days and the mid term survival.

RESULTS

We performed 81 carotid revascularisations on 70 patients. The mean age of the population studied was 83.5 (+/-2.8 years), (range 80-92). Twenty-four stenoses (29.6%) were symptomatic (23 transient ischemic accidents, 1 stroke), and 57 stenoses (70.4%) were asymptomatic. The mean degree of stenosis was 89.2+/-8.1% (based on NASCET evaluation). The main cardiovascular risk factor was arterial hypertension (95.7%). The overall perioperative death and stroke rate was 7.1%: 2 deaths, one of them related to a stroke, and 3 strokes (confidence interval: 2.4-15.9%). The perioperative death and stroke rate in the symptomatic stenosis group was 0%, and 8.8% in the asymptomatic stenosis group (p=0.163). No specific risk factor of neurologic events has been found except ASA 3 or higher (RR: 3.84 [1.2-12.1]). The mean follow up was 3.6 years (range 2-11.3), no patient was lost to follow-up. The Kaplan-Meier 5-year survival was 52%. The mean time to death was 3.5 years after the operation. Only 16.7% of these deaths were stroke-related.

CONCLUSIONS

Multicentric prospective studies, which have determined current recommendations for carotid surgery, did not include patients aged 79 years and older. In this particular population, the good results observed in our institution in the symptomatic carotid stenosis group would support the use of surgical treatment. The perioperative death and stroke rate observed for the asymptomatic group, clearly superior to current recommendations, suggests in our experience and especially for ASA> or =3, an individual evaluation to determinate the best indication.

Major elective surgery for vascular disease in patients aged 80 or more: perioperative (30-day) outcomes

Although major vascular surgery is performed with increasing frequency in elderly people, the impact of age on outcomes is uncertain. We evaluated the perioperative (30-day) outcomes for patients who underwent major elective vascular operations under general or peripheral anesthesia in their eighties and nineties in a 14-year period. Data for all consecutive 3,060 patients (456 of them > or years old) who underwent 3,314 elective vascular surgery procedures were prospectively entered into a computerized vascular registry. Detailed information was collected on patients' preoperative status, type of procedure and anesthesia, perioperative outcomes, and predictors of perioperative outcomes. The end points of the study were perioperative death and main surgical complications. Perioperative all-cause mortality rates varied across operations and were higher in elderly than in younger patients (1.4% vs. 0.2%, P = 0.014) after abdominal surgery (2.4% vs. 0.1%, P = 0.006) and especially after abdominal aortic aneurysm repair (2.8% vs. 0%, P = 0.035). In the elderly cohort, the mortality rate was <1% for almost 60% of all operations. In logistic regression analysis, only preoperative hypertension (odds ratio [OR] = 72.5, 95% confidence interval [CI] 9.4-557.6), congestive heart failure (OR = 16.5, 95% CI 2.3-115.9), and perioperative cardiac (OR = 20.7, 95% CI 1.6-273.8) and pulmonary (OR = 41.7, 95% CI 7.9-218.9) complications were associated with a higher 30-day death risk. In this series, perioperative outcomes were not influenced by the type of elective surgical procedure. Though overall mortality after major vascular surgery was higher in patients > or 80 years old, age per se was not an independent factor of a higher perioperative mortality risk or fatal and nonfatal complications.

Patient selection for carotid stenting versus endarterectomy: A systematic review

Carotid artery stenting has emerged as an alternative to carotid endarterectomy for the treatment of severe extracranial carotid stenosis in patients with anatomic or clinical factors that increase their risk of complications with surgery, yet there remains a substantial amount of variability and uncertainty in clinical practice in the referral of patients for stenting vs endarterectomy. By undertaking a thorough review of the literature, we sought to better define which subsets of patients with "high-risk" features would be likely to preferentially benefit from carotid stenting or carotid endarterectomy. Although only a single randomized trial comparing the outcomes of carotid stenting with distal protection and endarterectomy has been completed, a wealth of observational data was reviewed. Relative to endarterectomy, the results of carotid stenting seem favorable in the setting of several anatomic conditions that render surgery technically difficult, such as restenosis after prior endarterectomy, prior radical neck surgery, and previous radiation therapy involving the neck. The results of stenting are also favorable among patients with severe concomitant cardiac disease. Carotid endarterectomy, alternatively, seems to represent the procedure of choice among patients 80 years of age or older in the absence of other high-risk features. Overall, existing data support the concept that carotid stenting and endarterectomy represent complementary rather than competing modes of therapy. Pending the availability of randomized trial data to help guide procedural selection, which is likely many years away, an objective understanding of existing data is valuable to help select the optimal mode of revascularization therapy for patients with severe carotid artery disease who are at heightened surgical risk.

High-grade symptomatic and asymptomatic carotid stenosis in the very elderly. A challenge for proponents of carotid angioplasty and stenting

Background

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. 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.

Methods

A 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.

Results

In 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.

Conclusion

The 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.

Advancements in Carotid Stenting Leading to Reductions in Perioperative Morbidity among Patients 80 Years and Older

OBJECTIVE

Patients 80 years and older are generally considered to be at an increased risk for stroke and death from carotid endarterectomy. High-risk status often qualifies them for entry into a carotid angioplasty and stenting (CAS) trial. The aim of this study is to report periprocedure (0-30 d) morbidity and mortality among elderly patients undergoing CAS with and without distal embolic protection in an intention-to-treat analysis.

METHODS

A retrospective review was performed to evaluate the medical records and imaging studies of patients 80 years or older who underwent attempted CAS procedures with and without distal embolic protection between June 1996 and February 2004.

RESULTS

Ages of the 75 patients identified in our review ranged from 80 to 91 years (average 83.1 yr); 41 were men. Internal carotid artery stenosis ranged from 60 to 95% (mean 78.3%). Forty-two patients had symptoms (transient ischemic attack, 29; stroke, 13), and 33 patients were asymptomatic. Total event rates were major stroke, 4% (3 patients); minor stroke, 6.7% (5 patients); death, 4% (3 patients). Rates in the unprotected group (35 patients) were major stroke, 8.6% (3 patients); minor stroke, 5.7% (2 patients); major stroke/death, 14.3% (5 patients). Rates in the protected group (40 patients) were major stroke, 0; minor stroke, 7.5% (3 patients); major stroke/death, 0; (P < 0.05).

CONCLUSION

These results suggest that elderly patients undergoing CAS with adjunctive distal embolic protection are at a lower risk of periprocedure adverse events. Routine clopidogrel use, smaller hardware profile, patient selection, and increased experience likely contributed to these results.

Carotid endarterectomy in octogenarian veterans: does age affect outcome? A single-center experience

BACKGROUND

The efficacy of carotid endarterectomy (CEA) in octogenarians is controversial. Recent reports have examined this question in the general population, but little data exist on veterans. With the emergence of carotid artery stenting, we need to evaluate the role of CEA in treating elderly veterans with carotid stenosis.

METHODS

Retrospective chart review of all CEAs performed between January 1995 and December 2004.

RESULTS

A total of 286 procedures were performed in 239 patients; 39 procedures were performed in 33 octogenarians, and 247 procedures were performed in 206 younger veterans. Both groups had similar preoperative comorbidities. There were no statistically significant differences between octogenarians and younger veterans for postoperative stroke (2% vs. 1%), death (0% vs. 1%), myocardial infarction (5% vs. 2%), length of stay (7 +/- 19 vs. 3 +/- 8 days), or 4-year survival (53% vs. 57%).

CONCLUSIONS

CEA can be safely performed in octogenarian veterans with outcomes similar to younger veterans.

Carotid endarterectomy in octogenarians: Does increased age indicate “high risk?”

OBJECTIVE

Carotid endarterectomy (CEA) is proven to be the most effective treatment for symptomatic carotid artery stenosis of 50% or greater and asymptomatic carotid stenosis of 60% or greater. Although the prevalence of carotid artery disease increases with age, most prospective and randomized trials have excluded patients older than 80 years, implying that they are either at higher procedural risk or have decreased life expectancy. Since advanced age (>/=80 years) has been viewed as a "high-risk" indicator for CEA, age >/=80 years has been used as an indication for alternative treatment. The study was conducted to determine if age >/=80 years is related to increased morbidity, mortality, and length of stay in patients undergoing CEA.

METHODS

In the 12-year period from 1993 to 2004, 2217 CEAs were performed in 1961 patients. Three hundred sixty procedures were performed in 334 patients >/=80 years. Demographics, presentation, risk factors, operative outcome, and survival were analyzed. Contemporary literature was reviewed and the results summarized.

RESULTS

In patients aged >/=80 years, compared with their younger cohort, there was no difference in stroke (1.1% vs 0.8%, P = .333) but there was a higher operative mortality (1.9% vs 0.8%, P = .053). The combined stroke/death rate was higher in octogenarians (3.1% vs 1.5%, P = .041). This difference was due to the greater stroke/death rate in symptomatic octogenarians vs asymptomatic octogenarians (6.0% vs 0.9%, P = .007). The average postoperative length of stay was 3.2 +/- 4.8 days for octogenarians compared with 2.4 +/- 3.5 days for their younger counterparts ( P < .001). Thirty-seven percent of the octogenarians were discharged on the first postoperative day vs 51% ( P < .001), whereas 13% remained hospitalized beyond 5 days vs 8% ( P = .003). Although Kaplan-Meier survival curves show a higher mortality in octogenarians, survival after CEA approaches that of the overall population. A summary of the contemporary literature of CEA in 2204 patients >/=80 shows an operative stroke rate of 2.23% and death rate of 1.28%, with a combined stroke/death rate of 3.51%.

CONCLUSION

CEA is a safe and effective procedure in the octogenarian. The combined stroke/death rate is increased in patients aged >/=80, indicating increased risk, predominantly in symptomatic patients. Although CEA risk in octogenarians is higher compared with a younger cohort, outcomes remain within acceptable national guidelines and within outcome measures known to confer benefit compared with best medical care. Therefore, the term "high risk" should not be arbitrarily applied to patients reaching the 80-year threshold. This is confirmed by the contemporary literature.

Endovascular treatment of patients with carotid stenosis

Carotid artery stenting is a less invasive technique for carotid revascularization as compared with endarterectomy. However, clinical efficacy for carotid endarterectomy has been established through rigorous randomized clinical trials. Clinical trials and registries on carotid stenting to date have not been powered to compare differential efficacy with endarterectomy in symptomatic patients. Consequently, caution is recommended in use of carotid stenting, pending reports from larger randomized clinical trials.

Carotid artery stenting is associated with increased complications in octogenarians: 30-day stroke and death rates in the CREST lead-in phase

BACKGROUND

A heightened risk of stroke and death among octogenarians undergoing carotid artery stenting (CAS) has been reported. The multicenter Carotid Revascularization Endarterectomy vs. Stent Trial (CREST) supported by the National Institute of Neurological Disorders, National Institutes of Health, compares the efficacy of carotid endarterectomy (CEA) and CAS in an ongoing clinical trial. This effort also includes a "lead-in" phase of symptomatic (>50% stenosis) and asymptomatic (>70% stenosis) patients. The protocol calls for patients to receive aspirin and clopidogrel before and 30-days after CAS and to be examined by a study neurologist preprocedure, at 24-hours, and at 30-day. The occurrence of stroke and death was reviewed by an independent clinical events committee.

METHODS

The association of age and periprocedural stroke and death was examined in 749 lead-in patients undergoing CAS (30.7% symptomatic, 69.3% asymptomatic). Patients were separated into four age categories: less than 60, 60 to 69, 70 to 79, and 80 years or older, and the proportion of patients with stroke and death during the 30-day periprocedural period was calculated for each category.

RESULTS

An increasing proportion of patients suffered stroke and death with increasing age (P = .0006); 2 (1.7%) of 120 patients under age 60, 3 (1.3%) of 229 aged 60 to 69, 16 (5.3%) of 301 aged 70 to 79, and 12 (12.1%) of 99 patients aged 80 years and older. These increasingly high complication rates at older ages were not mediated by adjustment for symptomatic status, use of antiembolic devices, gender, percentage of carotid stenosis, or the presence of distal arterial tortuosity.

CONCLUSIONS

Interim results from the lead-in phase of CREST show that the periprocedural risk of stroke and death after CAS increases with age in the course of a credentialing registry. This effect is not mediated by potential confounding factors. Randomized trial data are needed to compare the CAS versus CEA periprocedural risk of stroke and death by age. Pending results from randomized studies, care should be taken when CAS is performed in older patient populations.

Cost Analysis of Carotid Endarterectomy: Is Age a Factor?

Carotid endarterectomy (CEA) has been demonstrated to be safe and effective in elderly patients. Our aim was to analyze and compare outcome and cost of CEA in both elderly and younger patient groups. A total of 125 consecutive patients who underwent CEA were examined retrospectively and grouped according to age (<80 years old, n = 95; and >or=80 years old, n = 30). The actual total costs and itemized costs were analyzed, and diagnosis-related group (DRG) code payor mix were identified. Patient demographics and risk factors were similar except for a greater incidence of coronary artery disease (CAD) in the >or=80 group than in these <80 (43.3% vs. 21.1%, p < 0.05). Patients had similar minor complication rates; however, the >or=80 group had higher perioperative major complications (16.7% vs. 1.1%, p < 0.01). There were no deaths and there was one perioperative stroke, which occurred in the <80 group. Mean length of stay (LOS), intensive care unit (ICU) LOS, and ICU admissions were greater in the >or=80 group. Cost figures were normalized to a base value of 10 US dollars to maintain proprietary data. Actual total costs of CEA were 131.50 US dollars for the >or=80 group and $100 for the <80 group (p < 0.001). Significant cost differences were found in ICU room costs, and costs for clinical laboratory, radiology imaging, other specialty consults, operating room, and ancillary services in the >or=80 group compared with the <80 group. These results show that the cost of CEA in the elderly is significantly greater than that for younger patients. This difference can be attributed to a greater number of major complications in the more elderly group, who require increased ICU stay, and thus require more clinical laboratory, radiology imaging, and specialty consult service resources. Consideration should be given for a DRG modifier code to increase hospital reimbursement for increased associated costs in elderly patients undergoing CEA.

Octogenarians with contralateral carotid artery occlusion: a cohort at higher risk for carotid endarterectomy?

PURPOSE

Carotid angioplasty and stenting has been proposed as a treatment option for carotid occlusive disease in patients at high risk, including those 80 years of age or older or with contralateral carotid occlusion. We analyzed 30-day mortality and stroke risk rates of carotid endarterectomy (CEA) in patients aged 80 years or older with concurrent carotid occlusive disease.

METHODS

From a retrospective review of 1000 patients undergoing 1150 CEA procedures to treat symptomatic and asymptomatic carotid lesions over 13 years, we identified 54 patients (5.4%) aged 80 years or older with concurrent contralateral carotid occlusion. These patients were compared with 38 patients (3.8%) aged 80 years or older with normal or diseased patent contralateral carotid artery and 81 patients (8.1%) younger than 80 years with contralateral carotid occlusion. All CEA procedures involved either standard CEA with patching or eversion CEA, and were performed by the same surgeon, with the patients under deep general anesthesia and cerebral protection involving continuous perioperative electroencephalographic monitoring for selective shunting. Shunting criteria were based exclusively on electroencephalographic abnormalities consistent with cerebral ischemia.

RESULTS

The 30-day mortality and stroke rate in patients aged 80 years or older with concurrent contralateral carotid occlusion was zero.

CONCLUSIONS

The concept of high-risk CEA needs to be revisited. Patients with two of the criteria considered high risk in the medical literature, that is, age 80 years or older and contralateral carotid occlusion, can undergo CEA with no greater risks or complications. Until prospective randomized trials designed to evaluate the role of carotid angioplasty and stenting have been completed, CEA should remain the standard treatment in such patients.

Contemporary management of "high-risk" patients with carotid stenosis

The concept of a "high-risk" carotid endarterectomy patient has been suggested in an effort to justify the application of carotid angioplasty and stenting outside of clinical trials. Contemporary results of carotid endarterectomy in this subgroup of patients would argue against the existence of a high-risk patient. Until randomized prospective trials establish the role of carotid angioplasty and stenting in carotid bifurcation disease, this new technology should be restricted to recurrent and radiation-induced disease.

The benefits of carotid endarterectomy in the octogenarian: a challenge to the results of carotid angioplasty and stenting

Proponents of carotid angioplasty and stenting (CAS) believe that this technique would be preferred over carotid endarterectomy (CEA) for the high-risk patient. Presumably this would include patients over 80 years of age. However, a recent large series of patients undergoing CAS revealed a 16% incidence of nonfatal strokes and deaths for patients over the age of 80; these results were significantly worse than those for younger patients undergoing CAS. The objective of this study was to reassess results of CEA in patients over 80, and to compare surgical results with the published results of CAS in this patient group. A review was conducted of a prospectively maintained database of all carotid surgery performed at our institution. Primary CEA that took place from 1997 through 1999 were included for analysis (n = 698). Our institutional results were compared with representative results from a recently published large series of CAS. Our analysis showed that CEA can be performed safely in the octogenarian, and results are equivalent to those of younger patients. CEA appears to have significantly better results in the octogenarian than CAS. The reasons for the poor outcomes of CAS in the octogenarian are unclear. The results of CAS in the older patient population are worrisome, and this "less invasive" technique may prove to be an inferior alternative in this patient group.

Carotid surgery in octogenarians: why not?

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.

Database Conference January 27-30, 2000, Washington D.C.--Do existing databases answer clinical questions about geriatric cardiovascular disease and stroke?

EXECUTIVE SUMMARY: Most randomized, controlled trials evaluating the effectiveness of pharmaceutical, surgical, and device interventions for the prevention and treatment of cardiovascular disease have excluded patients over 75 years of age. Consequently, the use of these therapies in the older population is based on extrapolation of safety and effectiveness data obtained from younger patients. However, there are many registries and observational databases that contain large amounts of data on patients 75 years of age and older, as well as on younger patients. Although conclusions from such data are limited, it is possible to define the characteristics of patients who did well and those who did poorly. The goal of this conference was to convene the principal investigators of these databases, and others in the field of geriatric cardiology, to address questions relating to the safety and effectiveness of treatment interventions for several cardiovascular conditions in the elderly. Seven committees discussed the following topics: (I) Risk Factor Modification in the Elderly; (II) Chronic Heart Failure; (III) Chronic Coronary Artery Disease: Role of Revascularization; (IV) Acute Myocardial Infarction; (V) Valve Surgery in the Elderly; (VI) Electrophysiology, Pacemaker, and Automatic Internal Cardioverter Defibrillators Databases; (VII) Carotid Endarterectomy in the Elderly. The chairs of these committees were asked to invite principal investigators of key databases in each of these areas to discuss and prepare a written statement concerning the available safety and efficacy data regarding interventions for these conditions and to identify and prioritize areas for future study. The ultimate goal is to stimulate further collaborative outcomes research in the elderly so as to place the treatment of cardiovascular disease on a more scientific basis.

Carotid endarterectomy in octogenerians

PURPOSE

The purpose of this study was to determine the safety and efficacy of carotid endarterectomy (CEA) in octogenerians.

METHODS

The records of 59 CEA performed in 57 patients who were 80yr or older between April 1993 and September 1998 were reviewed. There were 33 males and 24 females with a mean age of 82. Forty-nine procedures (83%) were performed for symptomatic carotid stenosis. The perioperative mortality and morbidity including neurological events were recorded. Long term follow-up data was also obtained.

RESULTS

There were three perioperative deaths (5.1%) and three perioperative neurological events, including one stroke (1.7%) and two transient ischemic attacks (3.4%). The combined mortality and stroke rate was 6.8%. With a mean follow-up of 25+/-21months, Kaplan-Meier estimates of the 4-yr survival rate, freedom from stroke, and stroke free survival were 78, 94 and 75% respectively. For comparison, during the same time period, the same group of surgeons performed 597 CEA in patients less than 80yr of age. The perioperative mortality and stroke rate was 0.3 and 2.5% respectively, with a combined mortality and stroke rate of 2.7%. Perioperative mortality was significantly higher in patients over 80yr of age (P<0.01).

CONCLUSIONS

CEA in octogenerians is associated with a higher mortality rate than in younger patients. However, good long term survival and freedom from stroke make CEA beneficial in octogenerians. With careful patient selection and perioperative management, CEA in octogenerians is worthwhile and should be advised in selected patients.

Carotid endarterectomy in the community hospital in patients age 80 and older

OBJECTIVE

To determine whether the rates of death and complications of carotid endarterectomy (CE) were different in the octogenarian population than in patients younger than age 80.

SUMMARY BACKGROUND DATA

The utility of CE depends on the ability of the surgeon and hospital to attain low rates of death and complications, including all subgroups of the patient population. In the past 30 years, the number of people age 85 and older has increased 274%.

METHODS

Detailed chart review was carried out on all CE procedures done from 1979 through 1998. Descriptive demographic data, risk factors, surgical details, length of stay, deaths, and complications were recorded.

RESULTS

A total of 2,398 CEs were performed in 1,970 patients; 2,180 procedures were performed in 1,783 patients younger than 80, and 218 CEs were performed in 187 patients age 80 and older. Sixty-five percent of the octogenarians and 67% of patients younger than age 80 had neurologic symptoms. Among asymptomatic patients, 89% had stenosis of 75% or more. There were 62 strokes in the 2,180 procedures in the younger group, for a stroke rate of 2.8%, and 7 strokes in the 218 procedures in the older group, for a stroke rate of 3.2%. The death rates were 0.9% for the octogenarians and 1.4% for the younger group.

CONCLUSIONS

Carotid endarterectomy can be safely performed in a community hospital in patients age 80 and older. Outcomes in octogenarians were not significantly different than those of younger patients and were within the range required for CE to be considered beneficial in the prevention of stroke.

Carotid endarterectomy in octogenarians: comparison with patient characteristics and outcomes in younger patients

OBJECTIVES

Carotid endarterectomy has been shown to be of clear benefit to selected patients. However, recent trials of carotid endarterectomy versus best medical therapy have excluded octogenarians, and some authors have suggested that carotid endarterectomy would have an unfavorable cost-benefit relationship in octogenarians. We compared patients and results for carotid endarterectomy in octogenarians and younger patients.

METHODS

We reviewed the results for 582 primary carotid endarterectomies (90 in octogenarians and 492 in younger patients) performed in 528 patients between February 1, 1985, and January 31, 1998 (all data were collected prospectively for the most recent 301 carotid endarterectomies). Conventional surgical technique was used with general anesthesia, selective shunting, and selective patching. Main outcome measures were perioperative and late ipsilateral stroke and death.

RESULTS

The two groups were similar with respect to indications for carotid endarterectomy and patient characteristics, except that octogenarians were more likely to have histories of congestive heart failure or hypertension and less likely to have histories of smoking or chronic lung disease. Carotid endarterectomy was performed for asymptomatic disease in 27% of the octogenarians and 33% of the younger patients (P =.31). Stenosis was >/=80% in 90% of the octogenarians and 78% of the younger patients (P =.014). Perioperative strokes, all of which were ipsilateral, occurred in one octogenarian (1.1%) and eight younger patients (1.6%, P = 1.00). No octogenarians and two younger patients died within 30 days of surgery (P = 1.00). Length of stay and direct costs associated with carotid endarterectomy were similar for octogenarians and younger patients. Late strokes occurred in two octogenarians (one ipsilateral) and four younger patients (two ipsilateral). Life table estimates of freedom from ipsilateral stroke at 2 years were 98% and 97% for octogenarians and younger patients, respectively (log-rank P =.69), and life table estimates of patient survival at 4 years were 81% and 89% for octogenarians and younger patients, respectively (P =.11). Octogenarians represented an increasing fraction of the carotid endarterectomies performed during the study period.

CONCLUSIONS

Octogenarians selected for carotid endarterectomy were similar to younger patients with respect to indications for carotid endarterectomy and comorbidities. Early mortality, early and late neurologic outcome, complications, and resource utilization were similar for the two groups, and more than 75% of octogenarians survived 4 years after undergoing carotid endarterectomy. Cost-benefit analyses for carotid endarterectomy, which are highly sensitive to expected patient survival, might not be pertinent to individual patient situations. Intellectually intact octogenarians without unusually severe comorbidities are good candidates for and should be offered the benefits of carotid endarterectomy.

Influence of age upon complications of carotid artery stenting. UAB Neurovascular Angioplasty Team

PURPOSE

To examine the impact of age upon the development of neurological and major systemic complications during or after carotid artery stenting.

METHODS

We reviewed the complications that occurred in patients undergoing elective carotid stent implantation between September 1994 and August 1996. The study population was then divided into 3 groups according to age: > or = 80 (group A), 75 to 79 (group B), and < or = 74 (group C) years. The rates of death, major and minor stroke, and myocardial infarction were compared among the groups, as well as with the rates reported by the major carotid endarterectomy (CEA) trials.

RESULTS

During the study period, 182 patients (216 vessels) were treated with carotid stenting. There were 19 (10.4%) complications: 1 (0.5%) death, 2 (1.1%) major strokes, 15 (8.2%) minor strokes, and 1 (0.5%) myocardial infarction. Neurological complications were clearly related to increased age with rates of 25.0% in group A versus 8.6% in group C (p = 0.042). The overall per patient rate of death or major stroke was 1.6% (1.4% per vessel).

CONCLUSIONS

Increasing age has a negative impact on the rate of complications in carotid stent patients. However, the majority of those complications are minor. The relative roles of medical therapy, stenting, and CEA in patients > 80 years of age must await the results of randomized trials.

Carotid endarterectomy in symptomatic and asymptomatic patients aged 75 years or more: perioperative mortality and stroke risk rates

The aim of this retrospective study was to determine whether age per se constitutes a contraindication to surgery in the elderly patient undergoing carotid endarterectomy (CEA) with regard to operative mortality and stroke risk morbidity. During an 8-year period, 96 patients aged 75 years or more underwent 103 CEAs. The age range was 75 to 89 years, with a median age of 79 and a mean age of 79.4 years. Fifty-nine CEAs with patch closure and 44 carotid eversion endarterectomies and reimplantation were performed for symptomatic (70.9%) and asymptomatic (29.1%) carotid lesions under general anesthesia and with continuous perioperative electroencephalographic (EEG) monitoring. In light of the efficacy and success achieved in this experience, advanced age does not seem in itself to contraindicate the performance of CEA; the surgical risk for elderly patients appears sufficiently low to justify the operation. A more aggressive approach may be warranted in elderly patients because of the morbidity and cost of the disease that it effectively prevents.

Carotid surgery in octogenarians in Veterans Affairs medical centers

The purpose of this study was to define outcomes after carotid surgery in octogenarians in the Veterans Affairs health care system. During fiscal years 1991-1994, 9152 patients in DRG 5 underwent extracranial vascular surgery procedures in Veterans Affairs medical centers. Those >/=80 years of age constituted 2.1% (n = 195) of such patients. In-hospital mortality rates were 1.03% (92/8957) in those <80 versus 3.08% (6/195) in those >/=80 years old (P = 0.018). Of those >/=80, 11.8% (23/195) had an ICD-9-CM-coded complication during hospitalization versus 11.2% of those <80 (1004/8957, NS). Surgical complications of the central nervous system (CNS) were present in 0.51% of octogenarians (1/195) and in 0.93% of those younger (83/8957, NS). Myocardial infarction (MI) occurred in 1.0% (2/195) of octogenarians and 0.74% (66/8967) of younger patients (NS). Patient Management Category software was used to define illness severity and resource intensity scale (RIS, a measure of resource utilization). Logistic regression analysis showed that age, illness severity, MI, and surgical complications of the CNS were associated with greater likelihood of mortality after extracranial vascular surgery. When the dichotomous variable "octogenarian status" was substituted for the continuous variable "age," in this model, there was no significant association of octogenarian status per se with mortality, though the association of illness severity, MI, and CNS complications with mortality persisted. Illness severity was greater for octogenarians (2.03 +/- 1.36) versus those younger (1.84 +/- 1.13, P < 0.05). RIS was 2.57 +/- 0.57 in octogenarians versus 2.47 +/- 0.48 for younger patients (P < 0.015). Length of stay (LOS) was a mean of 3.2 days longer for octogenarians (P < 0. 001). The risk of postoperative CNS complications was not higher in octogenarians. Mortality, resource utilization, and length of stay were, however, greater for octogenarians, but so was illness severity. Though mortality rates were greater for octogenarians in DRG 5, illness severity, MI, and postoperative CNS complications had greater impact on mortality after extracranial vascular surgery than octogenarian status per se.

Carotid endarterectomy in octogenarians: early results and late outcome

PURPOSE

This study was undertaken to determine the safety and efficacy of carotid endarterectomy (CEA) in the octogenarian population at the Cleveland Clinic.

METHODS

From 1989 to 1995, 182 CEAs were performed among 167 octogenarians (98 men, 69 women) with a mean age of 83 years (median, 83 years; range, 80 to 93 years). One hundred procedures (55%) were performed for severe asymptomatic stenosis, whereas 48 (26%) were performed for hemispheric transient ischemic attacks (TIAs) or amaurosis fugax, 24 (13%) for prior stroke, and 10 (5%) for vertebrobasilar symptoms. Thirteen CEAs (7%) were combined with myocardial revascularization, and another five (3%) represented carotid reoperations. Nine arteriotomies (5%) were closed primarily, whereas the remaining 173 (95%) were repaired using either vein patch angioplasty (141, 77%) or synthetic patches (32, 18%). Two patients were lost to follow-up, but late information was available for 165 patients (180 operations) at a mean interval of 2.7 years (median, 2.4 years; maximum, 7.4 years).

RESULTS

Considering all 182 procedures, there were five early (<30 days) postoperative neurologic events (2.7%), including three strokes (1.6%) and two TIAs (1.1%). An additional 15 neurologic events occurred during the late follow-up period, consisting of 11 strokes (6.1%) and four TIAs (2.2%). The Kaplan-Meier estimated 5-year rate of freedom from stroke was 85% (95% confidence interval [CI], 77% to 93%). There was one early postoperative death (0.6%) of cardiac complications 9 days after CEA. The estimated 5-year survival rate was 45% (95% CI, 33% to 57%), and the 5-year stroke-free survival rate was 42% (95% CI, 30% to 53%). Multivariable analysis yielded age at operation (p = 0.001), abnormal creatinine level (p = 0.025), and chronic obstructive pulmonary disease (p = 0.019) as variables that significantly influenced the survival rate. The presence of chronic obstructive pulmonary disease (p = 0.009) and, surprisingly, a lesser degree of contralateral internal carotid stenosis (p = 0.003) were found to be significantly associated with stroke after CEA. Causes of late death were cardiovascular in 16 patients (30%), unknown in 13 (24%), carcinoma in six (11%), stroke in six (11%), and miscellaneous in 13 (24%).

CONCLUSIONS

We conclude that CEA may be safely performed in selected octogenarians with carotid stenosis, and that the majority of these patients live the rest of their lives free from stroke. Therefore, age alone should not exclude otherwise-qualified candidates from consideration for CEA.

Entering the ninth decade is not a contraindication for carotid endarterectomy

The role of carotid endarterectomy (CEA) in stroke prevention is now better defined. However, its role in patients older than 79 years of age is controversial. This group of patients has been excluded in most clinical trials. In this study the authors reviewed their experience with CEA patients >79 years old. The records of all patients older than 79 years of age who underwent a CEA in a recent time period from January 1988 to December 1996 were retrospectively reviewed. Forty-one patients (31 men, 10 women) were identified by computer search. The indication for operation included transient ischemic attack in 12 (29.3%), amaurosis fugax in nine (22%), stroke in two (4.9%), and nonhemispheric symptoms in three (7.3%). Fifteen patients (36.6%) were asymptomatic. Medical risk factors included coronary artery disease in 26 (63.4%), hypertension in 22 (53.7%), and smoking in 12 (29.3%). The procedure was performed under EEG monitoring in all patients. General anesthesia was administered in 37 (90%) and regional anesthesia in four (10%). Shunts were used in four (10%) patients. The internal carotid artery was patched in 16 patients (39%). One patient (2.4%) developed a perioperative stroke and only one patient developed perioperative myocardial infarction (MI). None of the patients died within 30 days of surgery. In addition to the one MI case, five patients developed minor complications. The average length of time for stay after CEA was 3.4 days. Patients were followed up for an average of 20.7 months. Six patients died during follow-up. Four of those died from an MI and two from a stroke. The authors conclude that with proper selection of patients, CEA is safe in the octogenarian. Age alone should not be a contraindication for CEA.

Influence of age and hospital volume on the results of carotid endarterectomy: a statewide analysis of 9918 cases

PURPOSE

This study evaluated the impact of patient age and hospital volume on the results of carotid endarterectomy (CEA) in contemporary practice.

METHODS

The Maryland Health Services Cost Review Commission (MHSCRC) database was reviewed to identify all patients who underwent elective CEA as the primary procedure in all acute care hospitals in the state over the past 6 years.

RESULTS

From January 1990 through December 1995, 9918 elective CEAs were performed in 48 hospitals at a total charge of $68.9 million. Postoperative death and neurologic complications occurred in 90 (0.9%) and 166 (1.7%) cases, including 0.8% and 1.7%, 0.9% and 1.6%, 0.9% and 1.8%, and 1.4% and 1.3% of patients < 65 years, 65 to 69 years, 70 to 79 years, and > or = 80 years old, respectively. The mean length of stay and hospital charges increased linearly with increasing age: 4.2 days/$6550, 4.4 days/$6834, 4.8 days/$7059, and 5.6 days (p < 0.0001 vs others)/$7756 (p < 0.005 vs 70 to 79 years and p < 0.0003 vs < 70 years old), respectively, for patients < 65, 65 to 69, 70 to 79, and > or = 80 years old. The mortality rate was 1.9% in low-volume hospitals, 1.1% in moderate-volume hospitals, and 0.8% in high-volume hospitals. The neurologic complication rate was significantly higher (6.1%; p < 0.0001) in low-volume when compared with moderate-volume (1.3%) and high-volume (1.8%) hospitals.

CONCLUSIONS

CEA is a safe procedure in the majority of hospitals in contemporary practice, even among the very elderly, who may experience a longer length of stay and higher charges correlating with their documented greater medical complexity.

Extracranial arterial reconstruction for atheromatous stenotic disease

Risk factors for stroke and for carotid stenosis in the Japanese population are reviewed and the variations between rates of carotid endarterectomy in different populations discussed. The evolution of carotid plaques and the involvement of intraplaque hemorrhage in embolism and hemodynamic inadequacy in causing focal cerebral ischemic events are described. The indications for operation are presented together with an assessment of fitness for operation, with particular emphasis on the influence of heart disease on perioperative morbidity and late survival. Combined carotid and coronary reconstruction is carried out when severe disease of both systems is present (138 patients). The technique of carotid endarterectomy involves minimal dissection posterior to the common and internal carotid arteries to avoid vagal nerve injury. The pathology and symptoms of disease of the proximal great vessel together with techniques for revascularization are also presented.

Carotid endarterectomy in the octogenarian

During a 10-year period from January 1983 to December 1992, 79 carotid endarterectomies were performed in patients aged 80 years or older. This represented 7.4% of the total patient population undergoing carotid endarterectomy at Emory University Hospital. The indications for surgery in this elderly population were transient ischemic attacks in 24 (30.3%), cerebrovascular accident in 12 (15.2%), amaurosis fugax in seven (8.9%), vascular tinnitus in one (1.3%), and asymptomatic stenosis in 35 (44.3%). The average degree of ipsilateral stenosis was 76.8%. Concomitant risk factors included coronary artery disease in 43%, systemic arterial hypertension in 51.9%, diabetes mellitus in 10.1%, and significant smoking history in 53.2%. Seventy-six percent of the procedures were performed under local anesthesia, and in all but two intraluminal shunts were used. Combined 30-day mortality and postoperative stroke morbidity in this population was 1.3% (one patient). Long-term follow-up ranging from 1 to 10 years (average 35 months) revealed no ipsilateral strokes. This experience suggests that carotid endarterectomy can be performed in an elderly population with morbidity and mortality rates similar to those in a younger cohort.