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Carotid Revascularization in Elders: Which Method Is Preferred?

Summary and Comment |
November 19, 2013

Carotid Revascularization in Elders: Which Method Is Preferred?

  1. Seemant Chaturvedi, MD

A meta-analysis suggests that endarterectomy may be preferred among elders, but direct comparisons are needed.

  1. Seemant Chaturvedi, MD

Several clinical trials have been conducted in North America and Europe comparing carotid endarterectomy (CEA) and carotid artery stenting (CAS) in patients with symptomatic carotid stenosis. One trial (CREST) also included asymptomatic patients. These authors performed a meta-analysis of published carotid stenosis treatment studies that reported age-specific data, focusing on the outcomes of these procedures in elders. They identified 44 studies that involved 512,685 CEA procedures and 75,201 CAS procedures. The studies varied in their definition of elder, typically using an age cutoff of 75 or 80 years.

CEA was associated with significantly increased 30-day mortality in older versus younger patients (0.5% vs. 0.4%; odds ratio, 1.62), a difference that is not clinically significant. Rates of periprocedural stroke were similar. CAS was associated with increased periprocedural stroke in elders (OR, 1.56), but 30-day mortality was similar in older and younger patients (0.6% and 0.7%, respectively). Publication bias with CAS studies was considered high. More-recent publications showed a declining rate of periprocedural stroke and mortality with CAS.

Comment

This analysis is comprised mostly of single-center studies in which the quality of neurologic assessment during the postprocedural period is variable. Although periprocedural mortality with CEA was statistically higher in older patients than in younger patients, among elders mortality was slightly lower with CEA (0.5%) than with CAS (0.7%). Given these limitations, clinicians should consider the results of individual randomized clinical trials, which have consistently shown worse periprocedural outcomes for CAS in elders (age >70 years) than in younger patients. For elders, both CEA and CAS must be tested against modern aggressive medical therapy, in both symptomatic and asymptomatic patients. Only then will we know the true risk-benefit ratio of the two procedures.

  • Disclosures for Seemant Chaturvedi, MD at time of publication Consultant / Advisory board Abbott Vascular; Boeringher-Ingelheim; Genentech; Thornhill Research Grant / research support Pfizer Editorial boards Neurology; Stroke Leadership positions in professional societies American Academy of Neurology (Vice Chair of Vascular Neurology Section)

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