The contemporary role for carotid revascularization in older patients

Vascular specialists are increasingly confronted with clinical dilemmas surrounding the optimal role for carotid revascularization in an elderly patient population. Specifically, while carotid revascularization has been demonstrated to reduce the risk of ischemic stroke in appropriately selected patients, its application in elderly patients, particularly those who are asymptomatic, remains a focus of debate. This controversy stems largely from the exclusion of such older patients from the seminal trials that established the efficacy of revascularization over medical management. Furthermore, early studies have also highlighted concerns regarding elevated perioperative risk, prevalence of competing comorbidities, and limited life expectancy in this patient population, calling into question the marginal benefit of a revascularization procedure. However, more recent evidence suggests that with careful patient selection, elderly individuals can experience comparable outcomes to their younger counterparts. In particular, both carotid endarterectomy and transcarotid artery revascularization have demonstrated favorable safety and effectiveness profiles in octogenarians, and both appear to outperform transfemoral carotid artery stenting in terms of perioperative stroke/death risk. Importantly, contemporary risk assessment tools, including those incorporating frailty and anatomical complexity, highlight that age alone should likely not preclude intervention. Instead, these tools can be utilized to aid in performing an individualized and comprehensive risk assessment to inform shared decision making. In this review article, we will explore current controversies, supporting evidence, and important considerations when caring for older patients, specifically those over the age of 80 who are considering carotid revascularization.