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A Murine Model of Stent Implantation in the Carotid Artery for the Study of Restenosis
Published on: May 14, 2013
Safety and efficacy of carotid stenting in the very elderly
Arthur Grant1, Christopher White, Gary Ansel
1Cardiology Associates, Mobile, Alabama, USA. chipgrantmd@me.com
Insights
Carotid artery stenting (CAS) is safe for patients 80 and older, showing stroke and death rates comparable to younger individuals. Experienced operators and careful patient selection are key to these positive outcomes in very elderly patients.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Geriatric Medicine
Background:
- Carotid artery stenting (CAS) offers an alternative to carotid endarterectomy (CEA) for high-risk surgical patients.
- The very elderly (>=80 years) are a subgroup with increased surgical risk.
- Concerns exist regarding increased CAS complication risks in the very elderly, with prior reports showing higher stroke and death rates.
Purpose of the Study:
- To evaluate the safety and efficacy of CAS in patients aged 80 years and older.
- To assess stroke and death rates in a large cohort of very elderly patients undergoing CAS.
- To provide data on CAS outcomes in the very elderly with independent neurological assessment.
Main Methods:
- A consecutive series of 418 patients aged 80 years and older underwent CAS between 1994 and 2008 at four high-volume centers.
- Independent neurological assessment was performed post-procedure.
- Thirty-day follow-up data were available for 389 patients.
Main Results:
- The average patient age was 83.2 years; 63.2% were male.
- The majority of patients had comorbidities including hypertension (87.8%), coronary artery disease (74.4%), and dyslipidemia (71.1%).
- The overall 30-day incidence of stroke and death was 2.8%, with a cumulative incidence of major cardiovascular events at 3.3%.
Conclusions:
- CAS can be safely performed in very elderly patients (>=80 years).
- Stroke and death rates in this population are comparable to younger patients when CAS is performed by experienced operators.
- Careful patient selection and high-volume, experienced operators are crucial for achieving excellent CAS outcomes in the very elderly.
Background:
Carotid artery stenting (CAS) has emerged as an alternative to carotid endarterectomy (CEA) in patients at high risk for complications from surgery. The very elderly (>or=80-year-old) are one subgroup of patients identified as being at increased risk for carotid surgery. However, there is concern that the very elderly are also at increased risk for complications of CAS. A stroke and death rate of 12% was reported in very elderly patients during the roll-in phase of Carotid Revascularization Endarterectomy versus Stent Trial (CREST). We are reporting on a large clinical series of CAS with independent neurological assessment in the very elderly.
Methods:
Between 1994 and 2008, a consecutive series of 418 CAS patients (>or=80-year-old) were treated at four high-volume centers with extensive CAS experience. Independent neurologic assessment was performed after CAS procedures. Thirty-day follow-up information was available in 389 patients.
Results:
The average age was 83.2 +/- 2.8 years. Most patients were male (63.2%), and the target lesion carotid stenosis was asymptomatic in two-thirds (68.2%) of patients. The majority of patients treated with CAS had a history of coronary artery disease (74.4%), hypertension (87.8%), and dyslipidemia (71.1%). One third (30.1%) were diabetic and more than half (56.5%) were current or former smokers. Embolic protection devices (EPD) were used in 78.7% of cases with the CAS procedure being performed before EPD availability being the most common reason for not using them. The overall 30-day incidence of stroke and death was 2.8% (11/389). The cumulative incidence of major cardiovascular events (stroke, death, or myocardial infarction) during that time period was 3.3% (13/389).
Conclusions:
This large series of CAS with independent neurologic assessment is convincing evidence that the very elderly (>or=80 years) can safely undergo CAS with stroke and death rates comparable to younger patients. The key to obtaining these excellent results is that CAS be performed by high volume, experienced operators who exercise restraint regarding patient selection.
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