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Carotid endarterectomy as the criterion standard in high-risk elderly patients
Ahmed Suliman1, Joshua Greenberg, Ankur Chandra
1Section of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, CA 92103-8403, USA.
Insights
Carotid endarterectomy (CEA) is safe for elderly patients, with risks comparable to younger individuals. This procedure remains the gold standard for stroke prevention in older adults.
Area of Science:
- Vascular Surgery
- Neurology
- Geriatric Medicine
Background:
- Carotid angioplasty and stenting (CAS) is an alternative to carotid endarterectomy (CEA) for high-risk patients.
- Elderly patients (≥75 years) are often considered high-risk surgical candidates, with some studies reporting increased adverse outcomes with CAS.
Purpose of the Study:
- To evaluate the 30-day perioperative outcomes of CEA in patients aged 75 years and older.
- To assess the safety and efficacy of CEA in a traditionally high-risk surgical population.
Main Methods:
- Retrospective review of medical records from an academic tertiary care center.
- Analysis of 117 carotid endarterectomy procedures performed on 110 patients aged 75 years or older over a 16-year period.
Main Results:
- The study included patients with significant comorbidities, 50.4% symptomatic, 60.7% with >90% stenosis, and 44.4% with contralateral disease.
- The 30-day composite outcome of stroke, death, or myocardial infarction (MI) was low.
- Specific event rates included 1.7% stroke, 0.9% death, and 3.4% MI; the composite stroke or death rate was 2.6%.
Conclusions:
- Carotid endarterectomy is a safe procedure for elderly patients with comorbidities, offering periprocedural risks similar to younger patients.
- CEA is recommended as the criterion standard for stroke prevention in elderly patients, especially given potential increased stroke risks with CAS in this population.
Background:
Carotid angioplasty and stenting (CAS) is now a viable alternative to carotid endarterectomy (CEA) in patients considered to be high-risk candidates for surgery, despite recent reports of increased adverse periprocedural outcomes in elderly patients. We sought to evaluate our single-institution experience and the 30-day perioperative outcomes of CEA in patients 75 years or older, who are traditionally considered high-risk surgical candidates and are recommended for CAS.
Design:
Retrospective medical record review.
Setting:
Academic tertiary care center.
Patients:
All patients 75 years or older undergoing CEA during a 16-year period.
Main Outcome Measures:
Primary outcome of 30-day perioperative stroke, death, or myocardial infarction (MI) and a composite outcome of stroke, death, or MI. Secondary outcomes of all perioperative complications were exclusive of primary outcomes.
Results:
One hundred seventeen CEAs were performed in 110 patients 75 years or older. Significant medical comorbidities were well represented among the group. Among the patients, 50.4% were symptomatic, 60.7% had greater than 90% carotid stenosis, and 44.4% had contralateral disease. Primary outcome for any stroke, death, or MI was 1.7%, 0.9%, or 3.4%, respectively, with a composite event rate of any stroke or death of 2.6%. One or more secondary outcomes were experienced by 26.5% of patients.
Conclusions:
Carotid endarterectomy in elderly patients with significant comorbidities, traditionally thought to be a high-risk undertaking, is a safe procedure with periprocedural risks of stroke, death, and MI equivalent to those of younger patients. In light of the increased stroke risk in elderly patients with CAS, CEA remains the criterion standard for prevention of stroke in this patient population.
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