Carotid endarterectomy vs. stenting in the elderly: Debate continues

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Define 'elderly'

This study’s conclusions are not surprising, given that most clinicians have already seen them both in randomized prospective studies and in their own practices, said Dr. R. Clement Darling III.

However, the variation in the definition of "elderly" among the trials in this meta-analysis is a real concern: Sixty-four percent used 80 years as the cutoff, 31% used 75 years, and some used 70 or even 65 years as the cutoff.

"The bottom line is, carotid endarterectomy and carotid stenting seem to work equally well in younger patients, in expert hands. However, in the ‘elderly’ (at any age), endarterectomy has better outcomes with low morbidity, mortality, and stroke rate,’ and it remains the standard of care, he said.

Dr. Darling, of the Vascular Group, Albany, N.Y., made these remarks in an invited commentary (JAMA Surgery 2013 Oct. 23 [doi:10.1001/jamasurg.2013.4160]). He reported no financial conflicts of interest.



For elderly patients with carotid disease, carotid endarterectomy carries a lower risk of perioperative stroke or transient ischemic attack, the same risk of perioperative MI, and a slightly higher risk of perioperative death compared with carotid stenting, according to a meta-analysis. The results were published online Oct. 23 in JAMA Surgery.

However, the individual elderly patient’s vascular anatomy plays a crucial role in determining perioperative risk, as does his or her overall health and clinical profile.

"The results of [our] analysis suggest that careful consideration of a constellation of clinical and anatomic factors is required before an appropriate treatment of carotid disease in elderly patients is selected. The cardiovascular disease burden and general health of the individual patient should be meticulously evaluated before interventional instead of optimal medical treatment is applied," said Dr. George A. Antoniou of the department of vascular surgery, Hellenic Red Cross Hospital, Athens, and his associates.

Which treatment is the most appropriate for elderly patients with carotid disease is still much debated. Dr. Antoniou and his colleagues performed a comprehensive review of the medical literature since 1986 and a meta-analysis of 44 articles that directly compared outcomes in elderly patients with those of younger patients after carotid endarterectomy (39 studies) or carotid stenting (18 articles).

"Elderly" was defined as older than 80 years in most of these studies, and as older than 75 years in many, but there was great variability among the studies, and some even considered "older than 65 years" to be elderly.

Overall, the meta-analysis included 269,596 endarterectomies in elderly patients against 243,089 in younger patients, and 38,751 carotid stenting procedures in elderly patients against 36,450 in younger patients.

For endarterectomy, the rate of perioperative stroke was not significantly different between elderly (0.9%) and younger (1.2%) patients, nor was the rate of TIA (1.9% vs 1.8%, respectively). However, perioperative mortality was significantly higher in elderly (0.5%) than in younger (0.4%) patients.

In contrast, for carotid stenting, the rate of perioperative stroke was significantly higher for elderly patients (2.4%) than for younger patients (1.7%), as was the rate of TIA (3.6% vs 2.1%). And mortality was not significantly different between elderly patients (0.6%) and younger patients (0.7%), the researchers wrote (JAMA Surg. 2013 Oct. 23 [doi:10.1001/jamasurg.2013.4135]).

Both procedures were associated with an increased rate of perioperative MI in elderly patients, compared with younger patients. These rates were 2.2% in elderly patients, compared with 1.4% in younger patients undergoing endarterectomy; and 2.3% in elderly patients, compared with 1.5% in younger patients undergoing carotid stenting.

These findings remained robust in sensitivity analyses.

"It seems that endarterectomy is associated with improved neurologic outcomes compared with carotid stenting in elderly patients, at the expense of increased perioperative mortality." However, the small increase in mortality seen with endarterectomy – one-tenth of 1% – may not be clinically significant, Dr. Antoniou and his associates said.

Moreover, neurologic risk is closely tied to vascular anatomy. Elderly patients tend to have more unfavorable anatomy than do younger patients, but should be assessed on an individual basis. Unfavorable traits include heavily calcified and tortuous supra-aortic branches, as well as adverse morphology of the aortic arch such as elongation, distortion, and stenosis.

Manipulating the stenting instruments through such features may in itself raise the risk of neurologic sequelae. It also makes the procedure more technically difficult, which increases the risk of endothelial trauma, thrombus dislodgement, and thromboembolic events.

"In addition, elderly patients with significant extracranial atherosclerotic disease are likely to have a compromised cerebrovascular reserve, which makes them more susceptible to ischemic events from cerebral microembolization," the researchers said.

No financial conflicts of interest were disclosed.

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