Outcomes of carotid endarterectomy in symptomatic octogenarian patients

Carotid endarterectomy (CEA) is the standard treatment for symptomatic carotid artery stenosis (ipsilateral cerebral ischemic symptoms in the last 3months - SCS) in patients suitable for open surgery. Given the increasing age of the general population, this treatment is performed in octogenarian patients with increasing frequency. However, this population was not included in the historical randomized controlled trials and there is a lack of available data on perioperative complications, specifically the severity of possible postoperative stroke. The aim of this study is to report the outcomes of CEA for SCS in octogenarians and to evaluate the characteristics of postoperative stroke, in comparison to non-octogenarians.

This is a retrospective analysis of patients treated with CEA from 2012 to 2023 for SCS. Patients were divided according to their age in non-octogenarian (<80year-old) and octogenarian (≥80 year-old) and compared according to type of preoperative symptoms and timing of intervention. The primary endpoints of this study were to analyze the postoperative stroke and death rate and to assess the severity of postoperative stroke in octogenarian and non-octogenarian patients using the National Institute of Health Institute of Stroke Scale (NIHSS) classification. Follow-up was performed with yearly clinical visit.

A total of 664 symptomatic patients were treated by CEA, 157(24 %) were octogenarian (mean age 84 ± 4) and had similar preoperative characteristics of non-octogenarian except for the distribution of preoperative neurological type of symptoms: transient ischemic attack (TIA) 51 %vs42 %,P = .05, amaurosis fugax (AF) 14 %vs5 %,P = .001; stroke 36 %vs53 %,P = .01. The timing between symptoms and surgery was similar between the octogenarian and non-octogenarian patients 10 ± 8vs8 ± 7 days(P = .22). The overall postoperative rate of stroke and death was 3.1 %, similar between octogenarian and non-octogenarian: 3.7 %vs.3.1 %,P = .39. The type of preoperative symptoms did not affect the outcome between older and younger patients: TIA 3.4 %vs.3.3 %,P = .63; AF 0 %vs0 %,P = .1.0 and stroke 3.5 %vs.3.3 %,P = 1.0. In octogenarian patients stroke and death rate was similar independently on the timing of CEA performance: 3.9 %, if performed within 48h, 3.7 % between 2days and 14 days and 3.4 % after 2 weeks, P = .72. Postoperative stroke rate was similar in the two groups: 15(2.9 %) in non-octogenarians and 5(3 %) in octogenarian patients (P = .1); but moderate/severe stroke (NIHSS ≥ 5) was more frequent in octogenarian patients: 2 % vs 0.4 %, P = .05 The mean follow-up was 68±14 months and at 5-year the ipsilateral stroke free survival was 97.6 % ± 4 % with no differences between octogenarian and non-octogenarian: 95.2 % ± 6 %vs98.1 % ± 3 %,P = .32.

SCS octogenarian submitted to CEA have a low rate of perioperative and follow-up events, comparable with non-octogenarian. The timing and the type of symptoms do not seem to affect the CEA outcome. However, when a postoperative stroke occurs in the older patients, its severity is greater.