Metaanalysis of Procedural Stroke and Death among Octogenarians: Carotid Stenting versus Carotid Endarterectomy

Usman, Asad; Tang, Gale L.; Eskandari, Mark K.

doi:10.1016/j.jamcollsurg.2009.02.043

Cited by 28 publications

(11 citation statements)

References 61 publications

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“…16 In contrast to the SAPPHIRE trial, in standardrisk patients, a meta-analysis demonstrated increased risk of stroke in octogenarians undergoing CAS compared to CEA with CEA being a safer alternative. 17 Similarly, the Carotid RX Acculink/Accunet Post-Approval Trial to Uncover Unanticipated or Rare Events (CAPTURE) study—a multicenter postmarketing registry also found a higher event rate in octogenarians compared with the younger cohort (7% vs 4%). 18,19 Despite important implications of a potential impact of age on outcomes of CAS and CEA, little information is available from general practice settings.…”

Section: Discussionmentioning

confidence: 98%

Age differential between outcomes of carotid angioplasty and stent placement and carotid endarterectomy in general practice

Khatri

Chaudhry

Vázquez

et al. 2012

Journal of Vascular Surgery

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Background Data derived from prospective randomized clinical trials suggest differential comparative benefit between carotid angioplasty and stent (CAS) placement and carotid endarterectomy (CEA) in various age strata. We sought to investigate the impact of age on outcomes of CAS and CEA in general practice. Methods We analyzed the data from the Nationwide Inpatient Sample (NIS), which is representative of all admissions in the United States from 2005 to 2008. The primary end point was occurrence of stroke, cardiac complications, or death during the postprocedural period. Outcomes of interest were compared between patients aged ≥70 years and ≤70 years, undergoing CEA and CAS. Multivariate logistic regression was performed to determine the effect of age on occurrence of postoperative stroke, cardiac complications, or death. Covariates included in the logistic regression were patient’s age, gender, comorbid conditions, including hypertension, diabetes mellitus (DM), chronic lung disease, coronary artery disease (CAD), congestive heart failure (CHF), and renal failure; symptom status (symptomatic vs asymptomatic status), and hospital characteristics. Results Of the total 495,331 estimated patients who received treatment for CAD during the study period, 88% underwent CEA and the remaining 12% underwent CAS. Of the total procedures, 41% of the procedures were performed in patients aged <70 years compared to the remaining 59% that were performed among patients aged ≥70 years. For patients undergoing CAS, age >70 years was an important predictor of postoperative stroke (P = .0025; odds ratio [OR], 1.7; 95% confidence interval [CI], 1.2–2.5) and cardiac complications postprocedure (P = .045; OR, 1.3; 95% CI, 1.0–1.6). For patients undergoing CEA, age ≥70 years was associated with higher cardiac complications (P < .001; OR, 1.5; 95% CI, 1.3–1.7) and higher postoperative mortality risk (P = .0008; OR, 1.4; 95% CI, 1.1–1.8) compared to patients aged <70 years. The increased risk of composite end point (postoperative stroke/cardiac complications/ mortality) among patients aged >70 years was a significant factor for patients undergoing either CAS or CEA (OR of 1.3 for both procedures). Conclusion Our analysis suggests that most CAS and CEAs are performed in patients aged ≥70 years in general practice, and higher rates of postoperative complications are observed among these patients regardless of procedure choice.

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Section: Discussionmentioning

confidence: 98%

Age differential between outcomes of carotid angioplasty and stent placement and carotid endarterectomy in general practice

Khatri

Chaudhry

Vázquez

et al. 2012

Journal of Vascular Surgery

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“…A recent meta-analysis concerning carotid revascularization in octogenarians showed that the peri-procedural all-stroke rate was significantly higher during CAS [19]. The absolute risk on stroke was 3.46-times higher compared to patients undergoing CEA.…”

Section: Discussionmentioning

confidence: 99%

Is Age of 80 Years a Threshold for Carotid Revascularization?

Reichmann¹,

Lammeren²,

Moll³

et al. 2011

CCR

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Background and purpose:Carotid Angioplasty and Stenting (CAS) has emerged as an alternative to Carotid Endarterectomy (CEA) in treatment of carotid stenotic disease. With increasing life expectancy clinicians are more often confronted with patients of higher age. Octogenarians were often excluded from randomized trials comparing CAS to CEA because they were considered high-risk for revascularization. Conflicting results on the peri-procedural outcome of carotid revascularization in these patients have been reported. In order to objectively evaluate whether age above 80 years should be an upper limit for indicating carotid revascularization we systematically reviewed the currently available literature.Methods:Literature was systematically reviewed between January 2000 and June 2010 using Pubmed and Embase, to identify all relevant studies concerning CAS and CEA in octogenarians. Inclusion criteria were 1) reporting outcome on either CEA or CAS; and 2) data subanalysis on treatment outcome by age. The 30-day Major Adverse Event (MAE) rate (disabling stroke, myocardial infarction or death) was extracted as well as demographic features of included patients.Results:After exclusion of 23 articles, 46 studies were included in this review, 18 involving CAS and 28 involving CEA. A total of 2.963 CAS patients and 14.365 CEA patients with an age >80 years were reviewed. The MAE rate was 6.9% (range 1.6 - 24.0%) following CAS and 4.2% (range 0 – 8.8%) following CEA.A separate analysis in this review included the results of one major registry 140.376 patients) analyzing CEA in octogenarians only reporting on 30-day mortality and not on neurological or cardiac adverse events. When these data were included the MAE following CEA is 2.4% (range 0 – 8.8%)Conclusions:MAE rates after CEA in octogenarians are comparable with the results of large randomized trials in younger patients. Higher complication rates are described for CAS in octogenarians. In general, age > 80 years is not an absolute cut off point to exclude patients from carotid surgery. In our opinion, CEA should remain the golden standard in the treatment of significant carotid artery stenoses, even in the very elderly.

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“…Im Gegensatz wurde in fast allen Untersuchungspunkten ein tendenziell schlechteres Outcome bei der CAS-Gruppe beobachtet. Eine aktuell publizierte Metaanalyse von Usman et al zum Thema "CAS vs. CEA bei ≥ 80-Jährigen" [25] konnte zeigen, dass CASPatienten ein 3-fach erhöhtes Apoplexrisiko (7,04 % > 80 Jahre vs. 1,91 % < 80 Jahre) bei gleicher Mortalität und vergleichbarer Rate an perioperativen myokardialen Ischämien aufweisen [25]. Mögliche Ursache für das schlechte Abschneiden des CAS bei Patienten ≥ 80 Jahre liegt nach Meinung der Autoren in den morphologischen Gegebenheiten des oft verkalkten Aortenbogens.…”

Section: üBersicht 471unclassified

Gefäßchirurgie im Alter – Handlungsempfehlungen für die chirurgische Praxis

et al. 2011

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Due to the increasingly aging populations of the industrialised countries, the prevalence of vascular disorders is increasing, with an emerging patient subgroup of 80 years and older (octogenarians), often multi-morbid with an increased risk of anaesthesiological and surgical complications. This review article presents evidence-based indications for vascular surgery in the elderly (> 80 years), and the influence of advanced age on surgical results. Guidelines for daily practice were drawn from a thorough analysis of current treatment recommendations for three vascular disorders (carotid artery stenosis, abdominal aortic aneurysm, and peripheral arterial disease) with the aim of assisting the primary care physician in deciding upon the therapeutic management. In summary, evidence indicates that CEA (carotid endarterectomy) is the gold standard therapy for carotid artery stenosis, as opposed to the "best medical treatment" and CAS (carotid artery stenting). With suitable morphology of the aneurysm, endovascular aneurysm repair (EVAR) is the therapy of choice for abdominal aortic aneurysm (AAA). In elderly patients unfit for open repair and with a life expectancy of less than 4 years, EVAR does not offer any survival benefit compared with no intervention. In such patients, conservative therapy should be taken into consideration. Due to the significantly reduced life expectancy after a major amputation, the value of infrainguinal revascularisation is high, with the exception of patients aged > 90 years.

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Metaanalysis of Procedural Stroke and Death among Octogenarians: Carotid Stenting versus Carotid Endarterectomy

Cited by 28 publications

References 61 publications

Age differential between outcomes of carotid angioplasty and stent placement and carotid endarterectomy in general practice

Age differential between outcomes of carotid angioplasty and stent placement and carotid endarterectomy in general practice

Is Age of 80 Years a Threshold for Carotid Revascularization?

Gefäßchirurgie im Alter – Handlungsempfehlungen für die chirurgische Praxis

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