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Fahad S, Shirsath S, Metcalfe M, Elmallah A. Carotid Endarterectomy in the Very Elderly: Short-, Medium-, and Long-Term Outcomes. Vasc Specialist Int 2023; 39:28. [PMID: 37748930 PMCID: PMC10519940 DOI: 10.5758/vsi.230060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/11/2023] [Accepted: 08/21/2023] [Indexed: 09/27/2023] Open
Abstract
Purpose : Carotid endarterectomy (CEA) has an established effect on stroke-free survival in patients with carotid artery stenosis. Most landmark trials excluded patients ≥80 years of age due to their perceived high risk and uncertainty regarding the benefits of CEA. Despite the ongoing global increase in life expectancy, guidelines have not changed. The current study aimed to assess CEA outcomes in patients ≥80 years of age. Materials and Methods : Data from patients ≥80 years of age, who underwent CEA between April 2016 and April 2022, were collected. Demographic information, comorbidities, surgical details, operative details, outcomes, and post-CEA survival were reviewed, and long-term data up to April 2023 were collected. Results : Over the 6-year study period, 258 CEA procedures were recorded, of which 70 (27.1%) were performed in patients ≥80 years of age; the mean age was 84 years (range, 80-96 years), 47 (67.1%) were males, and 69 (98.6%) were symptomatic. Twenty-three (32.9%) patients were American Society of Anesthesiologists (ASA) grade 2, and 47 (67.1%) were grade 3. The 30-day stroke and mortality rates were 4.3% and 1.4%, respectively. At 1, 3, and 5 years, the cumulative freedom-from-stroke rates were 95.7%, 92.9%, and 91.4%, respectively, and the cumulative survival rates were 94.3%, 75.7%, and 61.4%, respectively. No risk factors affected early or late stroke or early mortality rates. Patients with ASA grade 3 had significantly lower cumulative survival than those with grade 2 (HR, 5.29; 95% CI, 1.590-17.603; P<0.01). Conclusion : CEA was safe and effective in average-risk, elderly patients. Higher risk patients (i.e., ASA 3) showed no increased 30-day risk for stroke or mortality but exhibited significantly worse long-term survival. Hence, careful consideration of the benefits before performing CEA is crucial.
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Affiliation(s)
- Shabin Fahad
- Herts and West Essex Vascular Network, The Lister Hospital, Hertfordshire, United Kingdom
| | - Sayali Shirsath
- Herts and West Essex Vascular Network, The Lister Hospital, Hertfordshire, United Kingdom
| | - Matthew Metcalfe
- Herts and West Essex Vascular Network, The Lister Hospital, Hertfordshire, United Kingdom
| | - Ahmed Elmallah
- Faculty of Medicine, Menofia University, Menofia Governorate, Egypt
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Leung YYR, Bera K, Urriza Rodriguez D, Dardik A, Mas JL, Simonte G, Rerkasem K, Howard DP. Safety of Carotid Endarterectomy for Symptomatic Stenosis by Age: Meta-Analysis With Individual Patient Data. Stroke 2023; 54:457-467. [PMID: 36647921 PMCID: PMC9855737 DOI: 10.1161/strokeaha.122.040819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 12/06/2022] [Indexed: 01/18/2023]
Abstract
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.
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Affiliation(s)
- Ya Yuan Rachel Leung
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, UK (Y.Y.R.L., D.P.J.H.)
| | - Kasia Bera
- Department of Vascular Surgery, Oxford University Hospitals NHS Trust, UK (K.B., D.U.R., D.P.J.H.)
| | - Daniel Urriza Rodriguez
- Department of Vascular Surgery, Oxford University Hospitals NHS Trust, UK (K.B., D.U.R., D.P.J.H.)
| | - Alan Dardik
- Yale Department of Surgery, Departments of Surgery and Cellular and Molecular Physiology, Yale School of Medicine, New Haven, CT (A.D.)
- Department of Surgery, VA Connecticut Healthcare System, West Haven (A.D.)
| | - Jean-Louis Mas
- Department of Neurology, GHU Paris, Hôpital Sainte-Anne, Université Paris-Cité, Inserm, France (J.-L.M.)
| | - Gioele Simonte
- Vascular and Endovascular Surgery Unit, Santa Maria della Misericordia, University of Perugia, Italy (G.S.)
| | - Kittipan Rerkasem
- Environmental - Occupational Health Sciences and Non-Communicable Diseases Research Group, Research Institute for Health Sciences, Chiang Mai University, Thailand (K.R.)
- Clinical Surgical Research Center, Department of Surgery, Faculty of Medicine, Chiang Mai University, Thailand (K.R.)
| | - Dominic P.J. Howard
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, UK (Y.Y.R.L., D.P.J.H.)
- Department of Vascular Surgery, Oxford University Hospitals NHS Trust, UK (K.B., D.U.R., D.P.J.H.)
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Heyer KS, Eskandari MK. Carotid stenting: risk factors for periprocedural stroke. Expert Rev Neurother 2014; 8:469-77. [DOI: 10.1586/14737175.8.3.469] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Reichmann BL, van Lammeren GW, Moll FL, de Borst GJ. Is age of 80 years a threshold for carotid revascularization? Curr Cardiol Rev 2012; 7:15-21. [PMID: 22294970 PMCID: PMC3131710 DOI: 10.2174/157340311795677716] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2010] [Revised: 10/16/2010] [Accepted: 01/07/2011] [Indexed: 11/22/2022] Open
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 literature. 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 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%) 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.
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Lichtman JH, Jones SB, Wang Y, Watanabe E, Allen NB, Fayad P, Goldstein LB. Postendarterectomy mortality in octogenarians and nonagenarians in the USA from 1993 to 1999. Cerebrovasc Dis 2009; 29:154-61. [PMID: 19955740 DOI: 10.1159/000262312] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Accepted: 09/11/2009] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Relatively little is known about trends in the utilization or outcomes of carotid endarterectomy (CEA) in the very elderly. We determined trends in the rates of CEA and perioperative (in-hospital and 30-day) and long-term (1-, 2-, 3-, 4- and 5-year) mortality in a US national sample of patients >or=80 years of age. METHODS All fee-for-service Medicare patients (80-89 and >or=90 years of age) who had a CEA [ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification): 38.12] from 1993 to 1999 were identified using the Centers for Medicare and Medicaid Services Inpatient Standard Analytic Files. Demographic characteristics and comorbid conditions were determined using ICD-9-CM diagnostic codes within the year prior to the index hospitalization for CEA. RESULTS A total of 140,376 CEA were performed in patients aged 80-89 years and 6,446 in those aged >or=90 years during this 7-year period. The annual number of operations increased from 13,115 in 1993 to 21,582 in 1999 for octogenarians, and from 481 in 1993 to 1,257 in 1999 for nonagenarians. Perioperative mortality was 2.2% in octogenarians and 3.3% in nonagenarians. Long-term mortality increased by approximately 10% per year after the operation, and was 43% in octogenarians and 56% in nonagenarians at 5 years. Perioperative mortality rates remained relatively stable over the 7-year period for both age groups although comorbidities increased. CONCLUSIONS The number of CEA performed in the very elderly in the USA increased from 1993 to 1999. Perioperative mortality rates were high compared with trial results, while long-term survivorship was comparable to that of similarly-aged peers in the USA.
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Affiliation(s)
- Judith H Lichtman
- Section of Chronic Disease Epidemiology, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT 06520-8034, USA. judith.lichtman @ yale.edu
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Ballotta E, Da Giau G, Ermani M, Meneghetti G, Saladini M, Manara R, Baracchini C. Early and long-term outcomes of carotid endarterectomy in the very elderly: An 18-year single-center study. J Vasc Surg 2009; 50:518-25. [DOI: 10.1016/j.jvs.2009.04.053] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2009] [Revised: 04/19/2009] [Accepted: 04/20/2009] [Indexed: 11/24/2022]
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Usman AA, Tang GL, Eskandari MK. Metaanalysis of Procedural Stroke and Death among Octogenarians: Carotid Stenting versus Carotid Endarterectomy. J Am Coll Surg 2009; 208:1124-31. [DOI: 10.1016/j.jamcollsurg.2009.02.043] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2009] [Revised: 02/06/2009] [Accepted: 02/09/2009] [Indexed: 10/20/2022]
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Chiam PTL, Roubin GS, Iyer SS, Green RM, Soffer DE, Brennan C, Vitek JJ. Carotid artery stenting in elderly patients: importance of case selection. Catheter Cardiovasc Interv 2008; 72:318-324. [PMID: 18726954 DOI: 10.1002/ccd.21620] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVES This study was conducted to determine if carotid stenting (CS) could be safely performed in the elderly. BACKGROUND Age has been shown to be a predictor of neurological complications during CS. We postulated that CS could be safely performed in elderly patients if certain anatomical and clinical markers such as excessive vascular tortuosity, heavy concentric calcification of the lesion, and decreased cerebral reserve were avoided. METHODS From July 2003 to October 2007, 142 patients aged > or =50% or asymptomatic stenosis > or =70%. All patients underwent carotid and cerebral angiography to determine anatomic suitability and stent risk. Demographic and outcome data were entered into a database; other data were obtained retrospectively. Independent neurology evaluation was performed before and at 24 hr after the procedure. RESULTS The mean age was 83.2 years, 62% were male, 25.5% were symptomatic, 8.5% had postcarotid endarterectomy restenosis, and 6.0% had contralateral internal carotid artery occlusion. There were no intracranial hemorrhages or periprocedural myocardial infarctions. One patient had amaurosis fugax. There were two minor and three major strokes in-hospital (3.3%). All patients had 30-day follow-up. One of the major strokes expired. Thus the overall 30-day stroke or death rate was 3.3% and major stroke or death rate was 2.0%. The 30-day stroke or death rate was 5.1% for symptomatic patients and 2.6% for asymptomatic patients. CONCLUSION CS can be performed safely in anatomically suitable elderly patients with low adverse event rates. CS should remain a revascularization option in appropriately selected elderly patients.
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Affiliation(s)
- Paul T L Chiam
- Department of Cardiac and Vascular Interventional Services, Lenox Hill Heart and Vascular Institute, New York
| | - Gary S Roubin
- Department of Cardiac and Vascular Interventional Services, Lenox Hill Heart and Vascular Institute, New York
| | - Sriram S Iyer
- Department of Cardiac and Vascular Interventional Services, Lenox Hill Heart and Vascular Institute, New York
| | - Richard M Green
- Department of Cardiac and Vascular Interventional Services, Lenox Hill Heart and Vascular Institute, New York
| | - Daniel E Soffer
- Department of Cardiac and Vascular Interventional Services, Lenox Hill Heart and Vascular Institute, New York
| | - Christina Brennan
- Department of Cardiac and Vascular Interventional Services, Lenox Hill Heart and Vascular Institute, New York
| | - Jiri J Vitek
- Department of Cardiac and Vascular Interventional Services, Lenox Hill Heart and Vascular Institute, New York
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Fitzgerald TN, Popp C, Federman DG, Dardik A. Success of Carotid Endarterectomy in Veterans: High Medical Risk Does Not Equate with High Surgical Risk. J Am Coll Surg 2008; 207:219-26. [DOI: 10.1016/j.jamcollsurg.2008.02.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2008] [Revised: 02/23/2008] [Accepted: 02/26/2008] [Indexed: 11/17/2022]
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Irwin C, Woodside KJ, Hunter GC. The role of carotid surgery in prevention of stroke in frail elderly patients. J Am Coll Surg 2006; 204:140-7. [PMID: 17189122 DOI: 10.1016/j.jamcollsurg.2006.09.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2006] [Revised: 09/20/2006] [Accepted: 09/21/2006] [Indexed: 11/22/2022]
Affiliation(s)
- Chance Irwin
- Department of Surgery, University of Texas Medical Branch, Galveston, TX 77555-0735, USA
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11
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Narins CR, Illig KA. Patient selection for carotid stenting versus endarterectomy: A systematic review. J Vasc Surg 2006; 44:661-72. [PMID: 16950453 DOI: 10.1016/j.jvs.2006.05.042] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2006] [Accepted: 05/20/2006] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Craig R Narins
- Division of Cardiology, University of Rochester Medical Center, NY 14642, USA.
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Villalobos HJ, Harrigan MR, Lau T, Wehman JC, Hanel RA, Levy EI, Guterman LR, Hopkins LN. Advancements in Carotid Stenting Leading to Reductions in Perioperative Morbidity among Patients 80 Years and Older. Neurosurgery 2006; 58:233-40; discussion 233-40. [PMID: 16462476 DOI: 10.1227/01.neu.0000194832.96470.cd] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Hunaldo J Villalobos
- Department of Neurosurgery and Toshiba Stroke Research Center, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo 14209, USA
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Stoner MC, Abbott WM, Wong DR, Hua HT, Lamuraglia GM, Kwolek CJ, Watkins MT, Agnihotri AK, Henderson WG, Khuri S, Cambria RP. Defining the high-risk patient for carotid endarterectomy: An analysis of the prospective National Surgical Quality Improvement Program database. J Vasc Surg 2006; 43:285-295; discussion 295-6. [PMID: 16476603 DOI: 10.1016/j.jvs.2005.10.069] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2005] [Accepted: 10/15/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Carotid endarterectomy (CEA) is the gold standard for the treatment of carotid stenosis, but carotid angioplasty and stenting has been advocated in high-risk patients. The definition of such a population has been elusive, particularly because the data are largely retrospective. Our study examined results for CEA in the National Surgical Quality Improvement Program database (both Veterans Affairs and private sector). METHODS National Surgical Quality Improvement Program data were gathered prospectively for all patients undergoing primary isolated CEA during the interval 2000 to 2003 at 123 Veterans Affairs and 14 private sector academic medical centers. Study end points included the 30-day occurrence of any stroke, death, or cardiac event. A variety of clinical, demographic, and operative variables were assessed with multivariate models to identify risk factors associated with the composite (stroke, death, or cardiac event) end point. Adjudication of end points was by trained nurse reviewers (previously validated). RESULTS A total of 13,622 CEAs were performed during the study period; 95% were on male patients, and 91% of cases were conducted within the Veterans Affairs sector. The average age was 68.6 +/- 0.1 years, and 42.1% of the population had no prior neurologic event. The composite stroke, death, or cardiac event rate was 4.0%; the stroke/death rate was 3.4%. Multivariate correlates of the composite outcome were (odds ratio, P value) as follows: deciles of age (1.13, .018), insulin-requiring diabetes (1.73, <.001), oral agent-controlled diabetes (1.39, .003), decade of pack-years smoking (1.04, >.001), history of transient ischemic attack (1.41, >.001), history of stroke (1.51, >.001), creatinine >1.5 mg/dL (1.48, >.001), hypoalbuminemia (1.49, >.001), and fourth quartile of operative time (1.44, >.001). Cardiopulmonary comorbid features did not affect the composite outcome in this model. Regional anesthesia was used in 2437 (18%) cases, with a resultant relative risk reduction for stroke (17%), death (24%), cardiac event (33%), and the composite outcome (31%; odds ratio, 0.69; P = .008). CONCLUSIONS Carotid endarterectomy results across a spectrum of Veterans Affairs and private sector hospitals compare favorably to contemporary studies. These data will assist in selecting patients who are at an increased risk for adverse outcomes. Use of regional anesthetic significantly reduced perioperative complications in a risk-adjusted model, thus suggesting that it is the anesthetic of choice when CEA is performed in high-risk patients.
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Affiliation(s)
- Michael C Stoner
- Division of Vascular and Endovascular Surgery, Masschusetts General Hospital, Boston, MA, USA.
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Bond R, Rerkasem K, Cuffe R, Rothwell PM. A Systematic Review of the Associations between Age and Sex and the Operative Risks of Carotid Endarterectomy. Cerebrovasc Dis 2005; 20:69-77. [PMID: 15976498 DOI: 10.1159/000086509] [Citation(s) in RCA: 116] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2005] [Accepted: 04/08/2005] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Randomized trials of carotid endarterectomy (CEA) for both symptomatic and asymptomatic carotid stenosis have demonstrated that benefit is decreased in women, due partly to a high operative risk, which is independent of age. However, it is uncertain whether these trial-based observations are generalisable to routine clinical practice. METHODS We performed a systematic review of all publications reporting data on the association between age and/or sex and procedural risk of stroke and/or death following CEA from 1980 to 2004. RESULTS 62 eligible papers reported relevant data. Females had a higher rate of operative stroke and death (25 studies, OR = 1.31, 95% CI = 1.17-1.47, p < 0.001) than males, but no increase in operative mortality (15 studies, OR = 1.05, 95% CI = 0.81-0.86, p = 0.78). Compared with younger patients, operative mortality was increased at > or =75 years (20 studies, OR = 1.36, 95% CI = 1.07-1.68, p = 0.02), at age > or =80 years (15 studies, OR = 1.80, 95% CI = 1.26-2.45, p < 0.001) and in older patients overall (35 studies, OR = 1.50, 95% CI = 1.26-1.78, p < 0.001). In contrast, risk of non-fatal stroke did not increase with age and so the combined perioperative risk was only slightly increased at age > or =75 years (21 studies, OR = 1.18, 95% CI = 0.94-1.44, p = 0.06), at age > or =80 years (10 studies, OR = 1.14, 95% CI = 0.92-1.36, p = 0.34) and in older patients overall (36 studies, OR = 1.17, 95% CI = 1.04-1.31, p = 0.01). CONCLUSIONS The effects of age and sex on the operative risk of CEA in published case series are consistent with those observed in the trials. Operative risk of stroke is increased in women and operative mortality is increased in patients aged > or =75 years.
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Affiliation(s)
- R Bond
- Stroke Prevention Research Unit, University Department of Clinical Neurology, Radcliffe Infirmary, Oxford, UK
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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; 200:734-41. [PMID: 15848366 DOI: 10.1016/j.jamcollsurg.2004.12.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2004] [Revised: 12/11/2004] [Accepted: 12/15/2004] [Indexed: 11/25/2022]
Abstract
BACKGROUND 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. STUDY DESIGN All patients in nonfederal Connecticut hospitals undergoing CEA between 1990 and 2002 were identified using the state discharge database (Chime Inc; ). RESULTS 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). CONCLUSIONS 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.
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Affiliation(s)
- Desarom Teso
- Department of Surgery, St Mary's Hospital, Waterbury, CT, USA
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Miller MT, Comerota AJ, Tzilinis A, Daoud Y, Hammerling J. Carotid endarterectomy in octogenarians: Does increased age indicate “high risk?”. J Vasc Surg 2005; 41:231-7. [PMID: 15768004 DOI: 10.1016/j.jvs.2004.11.021] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Alozairi O, MacKenzie RK, Morgan R, Cooper G, Engeset J, Brittenden J. Carotid endarterectomy in patients aged 75 and over: Early results and late outcome. Eur J Vasc Endovasc Surg 2003; 26:245-9. [PMID: 14509885 DOI: 10.1053/ejvs.2002.1939] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The mean age of patients in the European Carotid Surgery Trial with greater than 70% stenosis was 62 years. With changing demographics older patients are increasingly being referred for carotid endarterectomy (CEA). OBJECTIVES To assess the complications and survival (stroke-free and overall) of patients over the age of 75 undergoing CEA. METHODS Analysis of a database, clinical records and cause of death of patients undergoing CEA in a single regional unit over a 7 year period (1/4/1993 until 1/4/2000), with follow-up to April 2002. The rates of further neurological events were obtained from the Scottish Morbidity Record 1 (SMR 1) of hospital discharges. Patients referred from outside the region were excluded. Differences between groups were assessed by the Chi-squared test, with Yates correction and log-rank tests. RESULTS Of the 235 patients undergoing CEAs, 55 (23%) were 75 years or older. The post-operative neurological complication rate was 1.7% in the under 75's and 5.4% in the older group (p < 0.05). The 30 day mortality was 1.1% (two patients) and 1.8% (one patient) respectively. The Kaplan-Meier estimated survival for the under 75's and older were 93 and 75% at 3 years and 80 and 59% at 5 years respectively (p < 0.001). The Kaplan-Meier estimated neurological event-free 5 year survival for the under 75's and older patients were 96 and 82% respectively (p < 0.001). CONCLUSION CEA in patients aged 75 years and over is associated with a significantly increased risk of stroke and death. CEA may not benefit elderly patients with a reduced life expectancy.
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Affiliation(s)
- O Alozairi
- Department of Vascular Surgery, University of Aberdeen, Scotland, UK
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Rockman CB, Jacobowitz GR, Adelman MA, Lamparello PJ, Gagne PJ, Landis R, Riles TS. The benefits of carotid endarterectomy in the octogenarian: a challenge to the results of carotid angioplasty and stenting. Ann Vasc Surg 2003; 17:9-14. [PMID: 12522696 DOI: 10.1007/s10016-001-0330-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Caron B Rockman
- Division of Vascular Surgery, New York University Medical Center, New York, NY 10016, USA.
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