Management and outcomes of asymptomatic carotid stenosis in octogenarians and nonagenarians

As medicine evolves and life expectancy increases, octogenarians and nonagenarians represent growing populations that are at increased risk of ischemic stroke from asymptomatic carotid stenosis (ACS). Despite the significant disability and mortality that results from stroke in older adults, there are few data on the management of ACS in this population to inform clinical practice guidelines. The authors sought to assess the current body of literature on the management and outcomes of ACS in older adults. Prior landmark randomized controlled trials comparing carotid endarterectomy with best medical therapy alone have been questioned, as modern best medical therapy strategies have significantly evolved since their conception. These studies either do not include octogenarians and nonagenarians or involve a limited sample size, making it challenging to apply these findings to older adult population. Two particular areas of interest in our review are the potential benefits of carotid revascularization and risk stratification. Retrospective studies suggest that carotid endarterectomy may improve cognitive functioning in older adults. Frailty is shown to be associated with worse postoperative outcomes of carotid revascularization in the general population, although few data exist on the impact of frailty on outcomes in octogenarians and nonagenarians. Overall, there is a limited body of literature informing the clinical management of ACS in octogenarians and nonagenarians, and future randomized controlled trials are needed to compare outcomes of carotid revascularization with best medical therapy alone in this population.