Homocysteine improves risk stratification in patients undergoing endarterectomy for asymptomatic internal carotid artery stenosis
Nikolaus Duschek1, Samarth Ghai, Fahrudin Sejkic
1Department of Vascular and Endovascular Surgery, Wilhelminenspital, Vienna, Austria. nduschek@me.com
Insights
High homocysteine levels can predict survival in patients undergoing carotid endarterectomy (CEA). This biomarker helps identify older patients who may benefit more from medical therapy than surgery for asymptomatic carotid stenosis.
Area of Science:
- Vascular Surgery
- Biomarker Discovery
- Geriatric Medicine
Background:
- Carotid endarterectomy (CEA) offers limited benefit for patients with asymptomatic carotid artery stenosis and reduced life expectancy.
- Accurate prediction of postoperative survival is crucial for patient selection in CEA procedures.
Purpose of the Study:
- To evaluate plasma homocysteine as a biomarker for stratifying survival risk in patients undergoing CEA.
- To improve the prediction of postoperative survival and guide treatment decisions for asymptomatic carotid stenosis.
Main Methods:
- Prospective, nonrandomized case series of 214 patients undergoing CEA for asymptomatic internal carotid artery stenosis (2003-2012).
- Homocysteine levels and cardiovascular risk factors were used to compute prognostic indices.
- Kaplan-Meier curves estimated cumulative survival based on prognostic index quintiles.
Main Results:
- Total homocysteine significantly impacted postoperative survival (P<0.0001).
- Homocysteine-based prognostic indices improved survival prediction compared to age alone.
- Reclassification of surgical suitability occurred for 20.2% of patients >75 years and 14.6% of patients <75 years.
Conclusions:
- High plasma homocysteine levels indicate that older patients with asymptomatic carotid stenosis may benefit more from intensive medical therapy than CEA.
- Homocysteine serves as a valuable biomarker for optimizing treatment strategies in this patient population.
Background And Purpose:
A limited life expectancy reduces the benefit from carotid endarterectomy (CEA) for treatment of asymptomatic internal carotid artery stenosis. The aim of this study was to assess homocysteine as stratifying biomarker to improve prediction of postoperative survival.
Methods:
This was a prospective, nonrandomized case series from 2003 to 2012. Two hundred and fourteen consecutive patients (<75 years, n=130; ≥75 years, n=84) undergoing CEA for their asymptomatic internal carotid artery stenosis were observed for 8.5 years for the occurrence of death after CEA as primary end point (EC-nr: 04-067-0604). Homocysteine and major cardiovascular risk factors were used for computation of prognostic indices. Cumulative survival of prognostic indices-based quintiles was estimated by Kaplan-Meier curves.
Results:
Total homocysteine had a significant effect on postoperative survival (P<0.0001). Total homocysteine-based quintiles of prognostic indices showed a better prediction of the survival of the patients than age alone. This caused reclassification of 17 patients (20.2%)>75 years as fit for surgery, but also indicated a high risk for 19 patients (14.6%)<75 years. In the majority (79.8%) of patients aged>75 years, statistically, CEA could not be advised because of a significantly reduced 5-year survival rate.
Conclusions:
High plasma homocysteine levels suggest that older patients with asymptomatic carotid stenosis might rather benefit from intensive medical therapy than from CEA.
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