Carotid artery endarterectomy in patients over seventy years-of-age

Carotid surgery in the octogenarian

The records of 52 patients aged 80 years or older who underwent 56 carotid artery reconstructions were analyzed retrospectively. Four patients had amaurosis fugax, 27 patients had experienced one or more transient ischemic attacks, eight had a completely or partially reversible stroke, and 10 had vertebrobasilar insufficiency. Three patients were asymptomatic. Arteriograms documented stenosis > 80% on the operated side in 48 cases, whereas the contralateral carotid artery was occluded or had > 80% stenosis in 10 cases each. Two or more cerebral arteries were involved in 37 patients. CT scans were normal in only 21 (40%) patients. General anesthesia was used in 54 of 56 operations. Thirty-six endarterectomies, 18 bypasses, and two resection-anastomoses (for tortuosity) were performed. A shunt was employed in eight (14.3%) cases. One lethal stroke (1.9%) occurred during the first postoperative month. Three patients experienced nonfatal strokes, two of which gave rise to residual deficits. Two patients were lost to follow-up. For the remaining 49 patients the mean follow-up was 24 months. Two-year actuarial survival was 76.3% for the entire series and 67% for those surviving without neurologic events. This study shows that when properly selected the elderly population can safely undergo carotid surgery.

[Carotid endarterectomy in the elderly patient. Life table analysis and review of the literature based on 594 consecutive operations]

The significance of age as a prognostic factor was evaluated in patients undergoing carotid artery surgery between 12.8.86 and 31.10.92 in the Department of Vascular Surgery, Erlangen, 594 operations were performed on 546 consecutive patients using somatosensory evoked potentials as routine monitoring. Patients were divided into an older group of 139 (150 operations) with a mean age of 78.2 years and a younger group of 407 (444 operations) with a mean age of 64.4 years. There was no statistical difference in preoperative neurological status and number of risk factors, although there were different distributions of risk factors and concurrent illnesses. Thirty-day mortality rates were 1.7% for younger and 0.7% for older patients, and the incidence of postoperative stroke was 1.7% and 0.7% respectively (not statistically significant). Cumulative 5-year survival was 72.2% and 68.2% respectively. Cardiac diseases were the main cause of death in both groups, mainly fatal cardiac ischemia in younger patients and non-ischemic disease in the older patients. The 5-year stroke-free survival rate was 81% and 91.3% respectively (not significant). There was a trend towards a worse outcome for older patients with stages IIb and IV disease.

Carotid endarterectomy in elderly patients

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