Carotid artery disease in octogenarians: endarterectomy or stenting?

Carotid endarterectomy (CEA) is the gold standard for the treatment of carotid stenosis, but carotid angioplasty and stenting (CAS) has emerged as a potential less invasive therapeutic alternative to patients who would otherwise be considered as high risk for open surgery. The aim of this review was to pool the most current studies of the growing body of literature in which outcomes of CEA or CAS are compared in octogenarians and non-octogenarians to determine the current safety and efficacy of these therapeutic procedures, due to a lack of randomized controlled trials.

An electronic search of Medline, PubMed and Cochrane databases was supplemented by a review of bibliographies of relevant articles, as well as manual searches of relevant journals. Outcomes included 30-day stroke rate, death rate, combined stroke/death rate and myocardial infarction rate between octogenarians and non-octogenarians.

Randomized clinical trials or studies comparing CEA and CAS in the same study population were not identified. CEA and CAS outcomes, in octogenarians compared to younger cohorts, were evaluated in 10 and 5 studies, respectively. Analysis of data indicates no significant difference in adverse events reported in the two groups in the majority of studies of CEA, as opposed to the findings of CAS studies.

The current review supports the viewpoint that CEA remains the standard of care in octogenarians, towards which other procedures to prevent stroke should be compared. It also challenges the definition of the ''high-risk''/age blanket classification and suggests that until the longevity, safety and efficacy of CAS is established, wide applicability of CAS to such ''high-risk'' patients should be questioned and limited to ongoing controlled clinical trials.