Octogenarians with contralateral carotid artery occlusion: a cohort at higher risk for carotid endarterectomy?
Enzo Ballotta1, Laura Renon, Giuseppe Da Giau
1Section of Vascular Surgery, University of Padua School of Medicine, Padua, Italy. enzo.ballotta@unipd.it
Insights
Carotid endarterectomy (CEA) is safe for patients over 80 with contralateral carotid occlusion, showing zero mortality and stroke. This challenges the high-risk classification for CEA in this patient group.
Area of Science:
- Vascular Surgery
- Cerebrovascular Disease
Background:
- Carotid occlusive disease poses risks, with advanced age and contralateral occlusion considered high-risk factors.
- Carotid angioplasty and stenting (CAS) is an alternative for high-risk patients.
Purpose of the Study:
- To analyze the 30-day mortality and stroke risk rates of carotid endarterectomy (CEA) in patients aged 80 years or older with concurrent contralateral carotid occlusion.
Main Methods:
- Retrospective review of 1150 CEA procedures over 13 years.
- Identified 54 patients (5.4%) aged 80+ with contralateral carotid occlusion, compared with control groups.
- All procedures performed by a single surgeon using deep general anesthesia and EEG monitoring for cerebral protection.
Main Results:
- Zero 30-day mortality and stroke rate observed in patients aged 80 years or older with concurrent contralateral carotid occlusion.
Conclusions:
- The designation of 'high-risk' CEA requires re-evaluation for elderly patients with contralateral carotid occlusion.
- CEA can be performed in these patients without increased risk compared to current literature.
- CEA should remain the standard treatment until prospective trials on CAS are completed.
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.
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