Carotid Endarterectomy in the Community Hospital in Patients Age 80 and Older

Maxwell, J. Gary; Taylor, Andrew J.; Maxwell, Bryan G.; Brinker, Carla; Covington, Deborah L.; Tinsley, Ellis A.

doi:10.1097/00000658-200006000-00001

Cited by 45 publications

(26 citation statements)

References 19 publications

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“…The perioperative mortality rate in our octogenarian sample (2.2%) is consistent with other studies that report 30-day mortality rates between 0 and 3.6% [14,15,16,18,19,20,21,22,23,24,25,27,28,29,31,32,39,40]. Most of these studies were of modest sample size [14,15,16,18,19,20,21,22,23,24,25,27,28,29,32], included patients from single medical centers or states [15,16,20,22,23,24,25,26,27,32], or described outcomes within a single surgical practice [18,19].…”

Section: Discussionsupporting

confidence: 92%

“…Most of these studies were of modest sample size [14,15,16,18,19,20,21,22,23,24,25,27,28,29,32], included patients from single medical centers or states [15,16,20,22,23,24,25,26,27,32], or described outcomes within a single surgical practice [18,19]. Only a few studies reported rates for nonagenarians.…”

Section: Discussionmentioning

confidence: 99%

“…Octogenarians who undergo CEA have 30-day mortality rates ranging from 0 to 3.6% [14,15,16,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33]. The 5-year mortality rate for patients >80 years of age is estimated between 25 and 55%, based on data from 3 international and 1 US study, each with fewer than 200 patients [14,15,19,20].…”

Section: Introductionmentioning

confidence: 99%

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Postendarterectomy Mortality in Octogenarians and Nonagenarians in the USA from 1993 to 1999

et al. 2009

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Background: Relatively little is known about trends in the utilization or outcomes of carotid endarterectomy (CEA) in the very elderly. We determined trends in the rates of CEA and perioperative (in-hospital and 30-day) and long-term (1-, 2-, 3-, 4- and 5-year) mortality in a US national sample of patients ≧80 years of age. Methods: All fee-for-service Medicare patients (80–89 and ≧90 years of age) who had a CEA [ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification): 38.12] from 1993 to 1999 were identified using the Centers for Medicare and Medicaid Services Inpatient Standard Analytic Files. Demographic characteristics and comorbid conditions were determined using ICD-9-CM diagnostic codes within the year prior to the index hospitalization for CEA. Results: A total of 140,376 CEA were performed in patients aged 80–89 years and 6,446 in those aged ≧90 years during this 7-year period. The annual number of operations increased from 13,115 in 1993 to 21,582 in 1999 for octogenarians, and from 481 in 1993 to 1,257 in 1999 for nonagenarians. Perioperative mortality was 2.2% in octogenarians and 3.3% in nonagenarians. Long-term mortality increased by approximately 10% per year after the operation, and was 43% in octogenarians and 56% in nonagenarians at 5 years. Perioperative mortality rates remained relatively stable over the 7-year period for both age groups although comorbidities increased. Conclusions: The number of CEA performed in the very elderly in the USA increased from 1993 to 1999. Perioperative mortality rates were high compared with trial results, while long-term survivorship was comparable to that of similarly-aged peers in the USA.

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Section: Discussionsupporting

confidence: 92%

Section: Discussionmentioning

confidence: 99%

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Postendarterectomy Mortality in Octogenarians and Nonagenarians in the USA from 1993 to 1999

et al. 2009

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“…Of these, 7 papers reported risks in older patients but did not compare their results to younger patients in the same centre(s) and were therefore excluded. Among the 62 remaining eligible papers [35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97], there were no differences in the associations between either age or sex and overall 30-day stroke rate, death rate or combined stroke and death rate between studies reporting the associations as their primary aim and those which reported them as a subanalysis along with other risk factors (fig. 1, 2) and so data from both types of study are combined in the analyses below.…”

Section: Resultsmentioning

confidence: 99%

A Systematic Review of the Associations between Age and Sex and the Operative Risks of Carotid Endarterectomy

et al. 2005

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Background: Randomized trials of carotid endarterectomy (CEA) for both symptomatic and asymptomatic carotid stenosis have demonstrated that benefit is decreased in women, due partly to a high operative risk, which is independent of age. However, it is uncertain whether these trial-based observations are generalisable to routine clinical practice. Methods: We performed a systematic review of all publications reporting data on the association between age and/or sex and procedural risk of stroke and/or death following CEA from 1980 to 2004. Results: 62 eligible papers reported relevant data. Females had a higher rate of operative stroke and death (25 studies, OR = 1.31, 95% CI = 1.17–1.47, p < 0.001) than males, but no increase in operative mortality (15 studies, OR = 1.05, 95% CI = 0.81–0.86, p = 0.78). Compared with younger patients, operative mortality was increased at ≧75 years (20 studies, OR = 1.36, 95% CI = 1.07–1.68, p = 0.02), at age ≧80 years (15 studies, OR = 1.80, 95% CI = 1.26–2.45, p < 0.001) and in older patients overall (35 studies, OR = 1.50, 95% CI = 1.26–1.78, p < 0.001). In contrast, risk of non-fatal stroke did not increase with age and so the combined perioperative risk was only slightly increased at age ≧75 years (21 studies, OR = 1.18, 95% CI = 0.94–1.44, p = 0.06), at age ≧80 years (10 studies, OR = 1.14, 95% CI = 0.92–1.36, p = 0.34) and in older patients overall (36 studies, OR = 1.17, 95% CI = 1.04–1.31, p = 0.01). Conclusions: The effects of age and sex on the operative risk of CEA in published case series are consistent with those observed in the trials. Operative risk of stroke is increased in women and operative mortality is increased in patients aged ≧75 years.

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“…3 From observational studies, the periprocedural risk for the elderly undergoing CEA has been reported to be comparable to the risk for younger patients. [3][4][5] Nevertheless, subgroup analyses for age in several randomized trials revealed that periprocedural risk of stroke, myocardial infarction, and death after carotid artery stenting (CAS) increases with age. 6 -9 The occurrence of periprocedural stroke for CAS has been proposed to be closely related to plaque manipulation with intra-arterial devices resulting in plaque rupture, subsequent superimposed thrombus formation, and embolization of plaque debris.…”

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confidence: 99%

Atherosclerotic Plaque Vulnerability as an Explanation for the Increased Risk of Stroke in Elderly Undergoing Carotid Artery Stenting

Lammeren

Reichmann

Moll

et al. 2011

Stroke

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Background and Purpose-Recent randomized trials showed an increased periprocedural risk for stroke with increasing age in patients undergoing carotid artery stenting. Manipulation of atherosclerotic plaques during carotid artery stenting can result in plaque rupture with subsequent superimposed thrombus formation, embolization, and cerebrovascular events. We hypothesized that atherosclerotic plaques become more unstable with increasing age and thereby might provide insight into the age-related increased risk of cerebrovascular events during carotid artery stenting. Methods-Carotid atherosclerotic plaques were harvested from 1385 consecutive patients undergoing carotid endarterectomy between 2002 and 2010. Carotid plaques were quantitatively analyzed for macrophages, smooth muscle cells, and microvessels; and semiquantitatively analyzed for collagen, calcifications lipid cores, and intraplaque hemorrhages.Patients were divided in 4 groups by age: Ͻ60, 60 to 69, 70 to 79, and Ն80 years. Measures of association between age as a continuous variable and histological characteristics were also calculated. Results-Increasing age was associated with a decrease in the amount of smooth muscle cells in the carotid plaque. More plaques with large atheroma and heavy plaque calcifications were observed among elderly patients. After correction for baseline differences, risk factors, and medication use, age was independently associated with a more vulnerable carotid plaque composition. Conclusion-Plaque stability decreases gradually with age. Older patients with carotid stenosis have relatively unstable plaques with low smooth muscle cell content, a high amount of large lipid cores, and more calcified plaques as compared with younger patients. The underlying vulnerable plaque composition in the elderly might be an important contributing factor to the increased risk of stroke for older patients undergoing carotid artery stenting. (Stroke. 2011;42:2550-2555.)Key Words: age Ⅲ angioplasty & stenting Ⅲ atherosclerosis Ⅲ carotid stenosis Ⅲ plaque composition Ⅲ risk factors C arotid endarterectomy (CEA) reduces the risk of ischemic stroke in patients with a recently symptomatic, significant carotid artery stenosis. 1 Subgroup analysis revealed a high benefit from surgery, particularly for patients Ͼ75 years, due to the relatively high risk for a secondary event and therefore a relatively low number needed to treat to prevent 1 ipsilateral stroke. 2 Besides the favorable number needed to treat, overall life expectancy is rising, indicating that CEA in the "intellectually intact" elderly can be highly beneficial. 3 From observational studies, the periprocedural risk for the elderly undergoing CEA has been reported to be comparable to the risk for younger patients. 3-5 Nevertheless, subgroup analyses for age in several randomized trials revealed that periprocedural risk of stroke, myocardial infarction, and death after carotid artery stenting (CAS) increases with age. 6 -9 The occurrence of periprocedural stroke for CAS has been propos...

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Carotid Endarterectomy in the Community Hospital in Patients Age 80 and Older

Cited by 45 publications

References 19 publications

Postendarterectomy Mortality in Octogenarians and Nonagenarians in the USA from 1993 to 1999

Postendarterectomy Mortality in Octogenarians and Nonagenarians in the USA from 1993 to 1999

A Systematic Review of the Associations between Age and Sex and the Operative Risks of Carotid Endarterectomy

Atherosclerotic Plaque Vulnerability as an Explanation for the Increased Risk of Stroke in Elderly Undergoing Carotid Artery Stenting

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