Carotid Endarterectomy For Asymptomatic Carotid Stenosis In Octogenarians Is Still A Safe Option In The Current Era Of Superb Medical Therapy
Raul Sebastian, MD, Xiangyu Kuang, MS, Richard Amdur, PhD, Sara Zettervall, MD, Anton Sidawy, MD, Robyn Macsata, MD, Bao-Ngoc Nguyen, MD.
George Washington University Hospital, Washington, DC, USA.
Carotid Endarterectomy (CEA) is clearly the gold standard for stroke prevention in symptomatic patients. However, in the current era of superb medical therapy, the benefits of CEA in asymptomatic patients (especially octogenarians) are not completely clear. This study investigates whether this practice is supported by multicenter prospectively-collected data
Patients who underwent CEA for asymptomatic carotid stenosis were identified in the targeted module of the most updated NSQIP database from 2012-2015. Patients were stratified into two different groups: octogenarians (≥80 yo) and younger patients (<80 yo). Outcomes evaluated included 30-day mortality and major morbidities such as stroke, cardiac, pulmonary, renal dysfunctions. Multivariate logistic regression was used for data analysis
Results: We identified 9198 patients with asymptomatic carotid stenosis who underwent CEA, 1702 octogenarians and 7496 younger patients. There was no difference in pre-operative usage of anti-platelet and statins (89% vs. 90%, p = 0.9). Octogenarians were more likely to be female and have non-independent function status with higher ASA class. Although there was no difference in 30-day stroke between octogenarians and younger patients (1.02% vs 1.06%, p=0.8), octogenarians had higher 30-day mortality (1.0% vs 0.39%, p<0.01), cardiac complication (2.23% vs 1.32%, p<0.01), and risk of bleeding/return to the operating room (3.51% vs 2.35%, p<0.01). They stayed in the hospital longer (2.22 +/- 4.0 vs 1.89 +/- 3.7 days, p<0.01) and were less likely to be discharged to home (94.7% vs 97.2%, p<0.001). Multivariate analysis confirmed higher risk of mortality (OR, 2.8; 95% CI, 1.5-5.4; p<0.01), and cardiac complication (OR, 1.6; 95% CI, 1.1-2.4; p<0.05) (Table).
Carotid endarterectomy in octogenarians with asymptomatic carotid stenosis results in relatively higher mortality and cardiac complications than in younger patients. However, the absolute risk of stroke and mortality is still within 1% which is low and acceptable for this procedure. As a result, age alone should not be an absolute contraindication to CEA for asymptomatic stenosis. Individual patient characteristics such as anticipated longevity and preoperative functional status should be taken into consideration
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