Carotid endarterectomy in octogenarians: does increased age indicate "high risk?".

OBJECTIVE

Carotid endarterectomy (CEA) is proven to be the most effective treatment for symptomatic carotid artery stenosis of 50% or greater and asymptomatic carotid stenosis of 60% or greater. Although the prevalence of carotid artery disease increases with age, most prospective and randomized trials have excluded patients older than 80 years, implying that they are either at higher procedural risk or have decreased life expectancy. Since advanced age (>/=80 years) has been viewed as a "high-risk" indicator for CEA, age >/=80 years has been used as an indication for alternative treatment. The study was conducted to determine if age >/=80 years is related to increased morbidity, mortality, and length of stay in patients undergoing CEA.

METHODS

In the 12-year period from 1993 to 2004, 2217 CEAs were performed in 1961 patients. Three hundred sixty procedures were performed in 334 patients >/=80 years. Demographics, presentation, risk factors, operative outcome, and survival were analyzed. Contemporary literature was reviewed and the results summarized.

RESULTS

In patients aged >/=80 years, compared with their younger cohort, there was no difference in stroke (1.1% vs 0.8%, P = .333) but there was a higher operative mortality (1.9% vs 0.8%, P = .053). The combined stroke/death rate was higher in octogenarians (3.1% vs 1.5%, P = .041). This difference was due to the greater stroke/death rate in symptomatic octogenarians vs asymptomatic octogenarians (6.0% vs 0.9%, P = .007). The average postoperative length of stay was 3.2 +/- 4.8 days for octogenarians compared with 2.4 +/- 3.5 days for their younger counterparts ( P < .001). Thirty-seven percent of the octogenarians were discharged on the first postoperative day vs 51% ( P < .001), whereas 13% remained hospitalized beyond 5 days vs 8% ( P = .003). Although Kaplan-Meier survival curves show a higher mortality in octogenarians, survival after CEA approaches that of the overall population. A summary of the contemporary literature of CEA in 2204 patients >/=80 shows an operative stroke rate of 2.23% and death rate of 1.28%, with a combined stroke/death rate of 3.51%.

CONCLUSION

CEA is a safe and effective procedure in the octogenarian. The combined stroke/death rate is increased in patients aged >/=80, indicating increased risk, predominantly in symptomatic patients. Although CEA risk in octogenarians is higher compared with a younger cohort, outcomes remain within acceptable national guidelines and within outcome measures known to confer benefit compared with best medical care. Therefore, the term "high risk" should not be arbitrarily applied to patients reaching the 80-year threshold. This is confirmed by the contemporary literature.