Is carotid endarterectomy safe in patients over 80 years old?

From Nature Clinical Practice Cardiovascular Medicine (2005) 2, 382-383

Background
The most effective treatment for carotid artery stenosis is carotid endarterectomy (CEA). To date, randomized trials of this procedure versus best medical care have excluded patients aged 80 years or more, and consequently elderly individuals with this condition have been labeled 'high risk' for CEA, and are often treated with medical therapy or angioplasty and stenting.

Objective
To identify whether age of 80 years or more increases morbidity, mortality and length of hospital stay after CEA.

Design and intervention
This retrospective review of the Jobst Vascular Registry, a prospective record of vascular procedures carried out at the Toledo Hospital, Ohio, USA, analyzed all patients undergoing CEA between January 1993 and August 2004. The pretreatment characteristics, postoperative complications, surgical outcomes and length of hospitalization of patients were reviewed. Before CEA, patients underwent duplex ultrasonography and four-vessel cerebral arteriography. Most CEAs were performed under general anesthesia with intraoperative shunting; an autologous vein or synthetic patch was used to close the arteriotomy. Patients were monitored in intensive care for 24 h after CEA and followed up at day 7−10 postsurgery if no adverse events occurred.

Outcome measures
The main outcomes were procedure-related stroke and death. Length of hospital stay, destination after leaving hospital or in-hospital mortality, and complications were secondary outcomes. Operative mortality was defined as all deaths attributable to the procedure regardless of the time of occurrence, and included all deaths occurring within 30 days postoperatively, regardless of cause.

Results
In 1,961 patients in the registry, 2,217 CEAs were carried out: 334 patients aged 80 years or more underwent 360 procedures, and the remaining 1,627 patients under 80 years old underwent 1,857 CEAs. The occurrence of postoperative stroke did not differ significantly between the two age groups: 14 (0.8%) strokes occurred in patients under 80 years versus 4 (1.1%) in patients 80 years old or more. Operative mortality was slightly lower in the younger group, compared with the older group (0.8% versus 1.9%, respectively, P = 0.053). Mortality was similar in all asymptomatic patients, but was higher in older symptomatic than older asymptomatic patients (P = 0.007). The combined rate of stroke, death or both was higher in the older group than in the younger group (3.1% versus 1.5%, respectively, P = 0.041), the difference arising from the significantly higher rate seen in the older symptomatic patients compared with older asymptomatic patients. The average postoperative and total length of hospitalization was shorter in the younger than older group (P = 0.001). The groups had similar adverse event rates. Survival curve analysis demonstrated higher mortality in the older age group, however, this was similar to mortality in the normal, age-adjusted population.

Conclusion
Although increased, the combined stroke and death rate in patients aged 80 years or more falls within acceptable levels in national guidelines and compares favorably with best medical care. Miller et al. stress that patients over 80 years old should not be arbitrarily deemed 'high risk' for CEA.