Department of Surgery, The George Washington University Hospital, Washington, D.C..
Department of Surgery, The George Washington University Hospital, Washington, D.C.
J Vasc Surg. 2020 Feb;71(2):518-524. doi: 10.1016/j.jvs.2019.05.054. Epub 2019 Aug 27.
Carotid endarterectomy (CEA) is the gold standard to prevent a recurrent stroke in symptomatic patients with carotid stenosis. However, in the modern era, the benefit of CEA in asymptomatic octogenarian patients has come into question. This study investigates real-world outcomes of CEA in asymptomatic octogenarians.
Patients who underwent CEA for asymptomatic carotid stenosis were identified in the American College of Surgeons National Surgical Quality Improvement Program CEA-targeted database from 2012 to 2017. They were stratified into two groups: octogenarians (≥80 years old) and younger patients (<80 years old). The 30-day outcomes evaluated included mortality and major morbidities such as stroke, cardiac events, pulmonary, and renal dysfunction. Multivariable logistic regression was used for data analysis.
We identified 13,846 patients with asymptomatic carotid stenosis who underwent an elective CEA including 2509 octogenarians and 11,337 younger patients. Octogenarians were more likely to be female and less likely to be diabetic or smokers compared with younger patients. There was no difference in preoperative use of statins or antiplatelet therapy. Examination of 30-day outcomes revealed that octogenarians had slightly higher mortality (1.2% vs 0.5%; odds ratio, 2.1; 95% confidence interval, 1.3-3.4; P < .01), and a higher risk of return to the operating room (3.3% vs 2.3%; odds ratio, 1.4; 95% confidence interval, 1.1-1.9; P = .01). However, there was no difference between octogenarians and younger patients in adverse cardiac events or pulmonary, renal, or wound complications. Twenty-five octogenarian and 138 younger patients suffered from periprocedural stroke at a similar rate (1.0% vs 1.2%; P = .54). Stroke/death occurred for 51 of 2509 patients (2.0%) in the older group and 184 of 11,337 patients (1.6%) in the younger group, a difference that was not significant (P = .15).
The 30-day outcomes of CEA in octogenarians are comparable with those in younger patients. Although the octogenarians had slightly higher mortality than younger patients, the absolute risk of mortality was still low at 1.2%. Therefore, CEA is safe in asymptomatic carotid stenosis in octogenarians. Overall life expectancy and preoperative functional status, rather than age, should be the major determinants in the decision to operate.
颈动脉内膜切除术（CEA）是预防有症状颈动脉狭窄患者再次发生中风的金标准。然而，在现代，无症状 80 岁以上老年患者行 CEA 的获益受到了质疑。本研究旨在调查无症状 80 岁以上老年患者行 CEA 的真实世界结局。
在美国外科医师学会国家手术质量改进计划 CEA 靶向数据库中，我们确定了 2012 年至 2017 年间因无症状颈动脉狭窄而行 CEA 的患者。他们被分为两组：80 岁以上（≥80 岁）的患者和 80 岁以下的患者。术后 30 天的评估结果包括死亡率和主要的并发症，如中风、心脏事件、肺部和肾功能障碍。使用多变量逻辑回归进行数据分析。
我们共纳入 13846 例无症状颈动脉狭窄患者，他们接受了择期 CEA，其中 2509 例为 80 岁以上的患者，11337 例为 80 岁以下的患者。与年轻患者相比，80 岁以上的患者更可能为女性，且不太可能患有糖尿病或吸烟。两组患者术前他汀类药物或抗血小板治疗的使用无差异。对 30 天结局的分析显示，80 岁以上患者的死亡率略高（1.2%比 0.5%；比值比，2.1；95%置信区间，1.3-3.4；P<0.01），且重返手术室的风险更高（3.3%比 2.3%；比值比，1.4；95%置信区间，1.1-1.9；P=0.01）。然而，80 岁以上患者与年轻患者之间的心脏不良事件、肺部、肾脏或伤口并发症发生率无差异。25 例 80 岁以上患者和 138 例年轻患者发生围手术期中风的比例相似（1.0%比 1.2%；P=0.54）。在 2509 例 80 岁以上患者中，51 例（2.0%）和 11337 例 80 岁以下患者中 184 例（1.6%）发生卒中/死亡，差异无统计学意义（P=0.15）。
80 岁以上患者行 CEA 的 30 天结局与年轻患者相当。虽然 80 岁以上患者的死亡率略高于年轻患者，但死亡率绝对值仍较低，为 1.2%。因此，CEA 在无症状颈动脉狭窄的 80 岁以上老年患者中是安全的。总体预期寿命和术前功能状态，而不是年龄，应成为决定手术的主要因素。
