Carotid endarterectomy for asymptomatic carotid stenosis is safe in octogenarians

Carotid endarterectomy (CEA) is the gold standard to prevent a recurrent stroke in symptomatic patients with carotid stenosis. However, in the modern era, the benefit of CEA in asymptomatic octogenarian patients has come into question. This study investigates real-world outcomes of CEA in asymptomatic octogenarians.

Patients who underwent CEA for asymptomatic carotid stenosis were identified in the American College of Surgeons National Surgical Quality Improvement Program CEA-targeted database from 2012 to 2017. They were stratified into two groups: octogenarians (≥80 years old) and younger patients (<80 years old). The 30-day outcomes evaluated included mortality and major morbidities such as stroke, cardiac events, pulmonary, and renal dysfunction. Multivariable logistic regression was used for data analysis.

We identified 13,846 patients with asymptomatic carotid stenosis who underwent an elective CEA including 2509 octogenarians and 11,337 younger patients. Octogenarians were more likely to be female and less likely to be diabetic or smokers compared with younger patients. There was no difference in preoperative use of statins or antiplatelet therapy. Examination of 30-day outcomes revealed that octogenarians had slightly higher mortality (1.2% vs 0.5%; odds ratio, 2.1; 95% confidence interval, 1.3-3.4; P < .01), and a higher risk of return to the operating room (3.3% vs 2.3%; odds ratio, 1.4; 95% confidence interval, 1.1-1.9; P = .01). However, there was no difference between octogenarians and younger patients in adverse cardiac events or pulmonary, renal, or wound complications. Twenty-five octogenarian and 138 younger patients suffered from periprocedural stroke at a similar rate (1.0% vs 1.2%; P = .54). Stroke/death occurred for 51 of 2509 patients (2.0%) in the older group and 184 of 11,337 patients (1.6%) in the younger group, a difference that was not significant (P = .15).

The 30-day outcomes of CEA in octogenarians are comparable with those in younger patients. Although the octogenarians had slightly higher mortality than younger patients, the absolute risk of mortality was still low at 1.2%. Therefore, CEA is safe in asymptomatic carotid stenosis in octogenarians. Overall life expectancy and preoperative functional status, rather than age, should be the major determinants in the decision to operate.