Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, UK (Y.Y.R.L., D.P.J.H.).
Department of Vascular Surgery, Oxford University Hospitals NHS Trust, UK (K.B., D.U.R., D.P.J.H.).
Stroke. 2023 Feb;54(2):457-467. doi: 10.1161/STROKEAHA.122.040819. Epub 2023 Jan 17.
There is uncertainty whether elderly patients with symptomatic carotid stenosis have higher rates of adverse events following carotid endarterectomy. In trials, recurrent stroke risk on medical therapy alone increased with age, whereas operative stroke risk was not related. Few octogenarians were included in trials and there has been no systematic analysis of all study types. We aimed to evaluate the safety of carotid endarterectomy in symptomatic elderly patients, particularly in octogenarians.
We did a systematic review and meta-analysis of studies (from January 1, 1980 through March 1, 2022) reporting post carotid endarterectomy risk of stroke, myocardial infarction, and death in patients with symptomatic carotid stenosis. We included observational studies and interventional arms of randomized trials if the outcome rates (or the raw data to calculate these) were provided. Individual patient data from 4 prospective cohorts enabled multivariate analysis.
Of 47 studies (107 587 patients), risk of perioperative stroke was 2.04% (1.94-2.14) in octogenarians (390 strokes/19 101 patients) and 1.85% (1.75-1.95) in nonoctogenarians (1395/75 537); =0.046. Perioperative death was 1.09% (0.94-1.25) in octogenarians (203/18 702) and 0.53% (0.48-0.59) in nonoctogenarians (392/73 327); <0.001. Per 5-year age increment, a linear increase in perioperative stroke, myocardial infarction, and death were observed; =0.04 to 0.002. However, during the last 3 decades, perioperative stroke±death has declined significantly in octogenarians (7.78% [5.58-10.55] before year 2000 to 2.80% [2.56-3.04] after 2010); <0.001. In Individual patient data multivariate-analysis (5111 patients), age ≥85 years was independently associated with perioperative stroke (<0.001) and death (=0.005). Yet, survival was similar for octogenarians versus nonoctogenarians at 1-year (95.0% [93.2-96.5] versus 97.5% [96.4-98.6]; =0.08), as was 5-year stroke risk (11.93% [9.98-14.16]) versus 12.78% [11.65-13.61]; =0.24).
We found a modest increase in perioperative risk with age in symptomatic patients undergoing carotid endarterectomy. As stroke risk increases with age when on medical therapy alone, our findings support selective urgent intervention in symptomatic elderly patients.
对于有症状的颈动脉狭窄的老年患者，颈动脉内膜切除术（CEA）后发生不良事件的几率是否更高，目前仍存在不确定性。在临床试验中，单独接受药物治疗的复发性卒中风险随年龄的增长而增加，而手术性卒中风险则与之无关。试验中很少纳入 80 岁以上的患者，也没有对所有研究类型进行系统分析。我们旨在评估有症状的老年患者行 CEA 的安全性，特别是 80 岁以上的患者。
我们对 1980 年 1 月 1 日至 2022 年 3 月 1 日期间报道有症状颈动脉狭窄患者接受 CEA 后卒中、心肌梗死和死亡风险的颈动脉内膜切除术研究（包括观察性研究和随机试验的干预组）进行了系统评价和荟萃分析。如果提供了（或提供了计算这些的原始数据）术后风险的比率，我们将纳入观察性研究和随机试验的干预组。4 项前瞻性队列研究的个体患者数据可进行多变量分析。
在 47 项研究（107587 名患者）中，80 岁以上患者的围手术期卒中风险为 2.04%（1.94-2.14）（390 例/19101 例患者），非 80 岁以上患者的围手术期卒中风险为 1.85%（1.75-1.95）（1395 例/75537 例患者）；=0.046。80 岁以上患者的围手术期死亡率为 1.09%（0.94-1.25）（203 例/18702 例患者），非 80 岁以上患者的围手术期死亡率为 0.53%（0.48-0.59）（392 例/73327 例患者）；<0.001。每增加 5 岁，围手术期卒中、心肌梗死和死亡的风险呈线性增加；=0.04 至 0.002。然而，在过去的 30 年中，80 岁以上患者的围手术期卒中±死亡率显著下降（2000 年前的 7.78%[5.58-10.55]降至 2010 年后的 2.80%[2.56-3.04]）；<0.001。在个体患者数据的多变量分析（5111 例患者）中，年龄≥85 岁与围手术期卒中（<0.001）和死亡（=0.005）独立相关。然而，80 岁以上患者与非 80 岁以上患者的 1 年生存率相似（95.0%[93.2-96.5]与 97.5%[96.4-98.6]；=0.08），5 年卒中风险也相似（11.93%[9.98-14.16]与 12.78%[11.65-13.61]；=0.24）。
我们发现，在接受颈动脉内膜切除术的有症状患者中，随着年龄的增长，围手术期风险略有增加。由于单独接受药物治疗时的卒中风险会随年龄的增长而增加，因此我们的研究结果支持对有症状的老年患者进行有选择性的紧急干预。
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